Guideline Ministry of Health, NSW 73 Miller Street North Sydney NSW 2060 Locked Mail Bag 961 North Sydney NSW 2059 Telephone (02) 9391 9000 Fax (02) 9391 9101 http://www.health.nsw.gov.au/policies/ space space NSW Rural Paediatric Emergency Clinical Guidelines Second Edition space Document Number GL2014_007 Publication date 26-May-2014 Functional Sub group Clinical/ Patient Services - Baby and child Clinical/ Patient Services - Medical Treatment Summary Emergency Clinical Practice Guidelines to be used by Paediatric Advanced Clinical Nurses for initial treatment of infants and children presenting to emergency departments in rural areas. This Guideline, GL2014_007 replaces PD2011_047. Author Branch NSW Kids and Families Branch contact NSW Kids and Families 02 9391 9777 Applies to Local Health Districts, Chief Executive Governed Statutory Health Corporations, Specialty Network Governed Statutory Health Corporations, Affiliated Health Organisations, Public Hospitals Audience Emergency Departments, Paediatric Units, Nursing Distributed to Public Health System, Divisions of General Practice, NSW Ambulance Service, Ministry of Health, Private Hospitals and Day Procedure Centres, Tertiary Education Institutes Review date 26-May-2017 Policy Manual Patient Matters File No. H14/31240 Status Active Director-General
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Guideline
Ministry of Health, NSW73 Miller Street North Sydney NSW 2060
Locked Mail Bag 961 North Sydney NSW 2059Telephone (02) 9391 9000 Fax (02) 9391 9101
Functional Sub group Clinical/ Patient Services - Baby and childClinical/ Patient Services - Medical Treatment
Summary Emergency Clinical Practice Guidelines to be used by PaediatricAdvanced Clinical Nurses for initial treatment of infants and childrenpresenting to emergency departments in rural areas. This Guideline,GL2014_007 replaces PD2011_047.
Author Branch NSW Kids and Families
Branch contact NSW Kids and Families 02 9391 9777
Applies to Local Health Districts, Chief Executive Governed Statutory HealthCorporations, Specialty Network Governed Statutory HealthCorporations, Affiliated Health Organisations, Public Hospitals
Distributed to Public Health System, Divisions of General Practice, NSW AmbulanceService, Ministry of Health, Private Hospitals and Day Procedure Centres,Tertiary Education Institutes
PURPOSE These Clinical Guidelines provide a clear standard of initial care for children who present to Emergency Departments where Medical Officers are not immediately available. It is intended that the Clinical Guidelines will be used by Paediatric Advanced Clinical Nurses to facilitate the early and appropriate clinical management of children who present to Emergency Departments with acute and life threatening conditions and to relieve pain and discomfort. This is the second edition of the document which has been developed in line with current best practice and advice from expert reviewers. This document is a companion document to the NSW Rural Adult Emergency Clinical Guidelines.
KEY PRINCIPLES These NSW Rural Paediatric Emergency Clinical Guidelines are underpinned by the following principles: A ‘graduated’ clinical response is required depending on the:
• Severity of the presenting emergency condition e.g. the clinical response to patients with mild to moderately severe asthma is different to that for patients with immediately life threatening asthma
• Level of training and expertise of the nursing staff who initiate the management of the patient i.e. Registered Nurses with advanced clinical training will practice more advanced interventions. Nursing staff using these clinical guidelines are required to be appropriately educated, skilled and credentialed. The shaded portions contained in the treatment guidelines must only be used by RNs who are recognised as Advanced Clinical Nurses
• Legal requirements for nurses who initiate treatment and administer medications based on medication standing orders
• Need for flexibility to respond to input from senior clinical staff and medical officers to accommodate local circumstances.
The Clinical Guidelines reflect evidence based best clinical practice and expert consensus opinion, in regards to standardisation of initial clinical management of specific paediatric conditions and alignment with the principles outlined in the First Line Emergency Care Course (FLECC) for Registered Nurses. Any medication standing orders contained in these clinical guidelines will have no legal basis unless they are approved by the Local Health District Drug Therapeutic Committee (or local hospital Drug Therapeutic Committee if there is no District Committee), as specified in NSW Health Policy Directive PD2013_043, Medication Handling in NSW Public Health Facilities, (Section 7.4 Standing Orders). Each standing order must be signed and dated by an appropriate senior Medical Officer and by the Chairperson of the Drug Committee that is approving the standing order. The
GL2014_007 Issue date: May-2014 Page 1 of 2
GUIDELINE SUMMARY committee must review the standing order annually and re-endorse and date the standing order to confirm on-going approval.
USE OF THE GUIDELINE These guidelines are to be used for children up to their 16th birthday only and have been formatted to follow the generally accepted Airway, Breathing, Circulation and Disability (ABCD) approach for managing emergency/critically ill patients. Advanced Clinical Nurses have advanced knowledge and skills, have completed an advanced emergency or critical care nursing course or hold a graduate certificate/diploma in paediatric nursing – emergency stream and have been deemed competent to carry out these advanced roles using contemporary assessment and ongoing credentialing processes. Where an Advanced Clinical Nurse utilises these guidelines the:
• Designated medical officer will be notified as soon as practicable • Medical Officer will review any patient who has been given medications
consistent with the standing orders contained within this document as soon as possible (must be within 24 hours). At the time of this review the Medical Officer must check and countersign the nurse record of administration on the medication chart.
A number of the incorporated procedures have been adapted from the NSW Health Acute Paediatric Clinical Practice Guidelines. Where applicable and advised, subsequent treatment and management should follow the NSW Health Paediatric Clinical Practice Guidelines.
REVISION HISTORY Version Approved by Amendment notes May 2014 (GL2014_007)
Deputy Secretary Population and Public Health
Second edition. Guidelines updated to align with:
• Parameters of Standard Paediatric Observation Chart (SPOC)
• Paediatric Clinical Practice Guidelines- particularly Recognition of the Sick Baby and Child;
• DETECT Junior; • Paediatric Sepsis Pathway and • Clinical Escalation and Response Systems.
AcknowledgementsThese Guidelines were originally developed by the NSW Child Health Networks
Paediatric Clinical Nurse Consultant Group in consultation with the NSW Rural
Critical Care Task Force, NSW Rural Critical Care CNC Planning Group, the
Clinical Excellence Commission, and Statewide Services Development Branch,
between 2005-2012. There has been significant direction and contribution
by the specialist clinicians in the field. The considerable effort of all involved
is acknowledged. We also acknowledge the valuable contribution of the
critical readers.
NSW MINISTRY OF HEALTH NSW Kids and Families73 Miller StreetNORTH SYDNEY NSW 2060Tel: (02) 9391 9491Fax: (02) 9391 9928TTY: (02) 9391 9900
www.health.nsw.gov.au
This work is copyright. It may be reproduced in whole or in partfor study training purposes subject to the inclusion of an acknowledgementof the source. It may not be reproduced for commercial usage or sale.Reproduction for purposes other than those indicated above, requires written permission from the NSW Ministry of Health.
This Clinical Practice Guideline is extracted from the GL2014_007 and as a result, this booklet may be varied, withdrawn or replaced at any time.
Further copies of this report can be downloaded from the:NSW Health website: www.health.nsw.gov.au
Content within this publication was accurate at the time of publication.
May 2014
NSW HEALTH 2014 Rural Paediatric Emergency Clinical Guidelines – 2nd Edition PAGE i
The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Paediatric Advanced Clinical Nurses.
The NSW Rural Paediatric Emergency Clinical Guidelines
are to be implemented for the emergency management
of paediatric patients only.
A child is defined as up to their 16th birthday.
NSW Health PD2010_033 Children and Adolescents – Safety and Security in NSW Health Acute Facilities
Newborn and paediatric Emergency Transport Service
(NETS) 1300 36 2500
The NSW Rural Paediatric Emergency Clinical Guidelines are aligned with the Standard Paediatric Observation Charts, Clinical Emergency Response System, NSW Acute Paediatric
Clinical Practice Guidelines, DETECT Junior and the Paediatric Sepsis Pathway.
NSW HEALTH 2014 Rural Paediatric Emergency Clinical Guidelines – 2nd Edition PAGE ii
The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Paediatric Advanced Clinical Nurses.
Assessing children Medical Officer must be notified immediately For paediatrics only
The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Paediatric Advanced Clinical Nurses.
Remember:n Size and relative body proportions change with age.
n Treatment and management regimes are related to
age and weight.
n Infants and children are more prone to hypothermia,
due to their large body surface area to mass ratio.
It is very important to keep them warm.
n Infants and young children are prone to
hypoglycaemia. Check blood glucose level regularly.n Children have unique psychological needs.
All drug doses and fluids are calculated on body
weight. It is essential that all children are weighed
on presentation to the Emergency Department. If
exceptional circumstances exist and this is not possible,
then the following weight for age formula can be used
0-12 months wt kg = (0.5 x age in mths) + 4
1-5 yrs wt kg = (2 x age in yrs) + 8
6-12 yrs wt kg = (3 x age in yrs) + 7
An alternative to ascertaining the weight is the
Broselow™ Paediatric Emergency Tape.
Why children are different The following table provides a brief overview of the
important differences in infants and children and the
subsequent implications for your practice.
Airway and breathing When assessing respiratory rate, rhythm and pattern
count for a full minute.
Note: By approximately 8 years of age a child’s airway
anatomy and physiology approximates that of adults.
Differences Implications
Children less than 2 years have a proportionally large head and short neck.
Shorter and softer trachea.
Greater risk of neck flexion or overextension which may cause tracheal compression and airway obstruction.
Comparatively large tongue, a small mouth and soft oropharynx.
Easily obstructed, damaged and prone to swelling.
Infants less than 6 months of age are preferential nasal breathers.
More easily obstructed by secretions.
Secretions in the nose may impede airway patency.
Narrower airways. More easily obstructed by secretions and foreign bodies.
Diaphragmatic breathers.Impeded diaphragmatic contraction (caused for example by abdominal distension) can increase or lead to respiratory distress.
Epiglottis is horse shoe shaped and projects posteriorly at 45˚.
Intubation can be difficult.
The larynx is high and anterior.A straight blade is preferred when intubating an infant.
Children are more prone to aspiration.
Cricoid ring is the narrowest point of the airway and susceptible to oedema.
Uncuffed tubes are often used.
Intercostal muscle is underdeveloped with fewer type 1 fibres than adults. (Less than 5 years).
Ribs are more horizontal.
These muscles stabilise but do not lift the chest wall. They become easily fatigued and cannot sustain long periods of increased respiratory demand.
The cartilaginous chest wall is more compliant. The child’s ability to maintain functional residual capacity or increase their tidal volume during respiratory distress is compromised.
Chest wall very thin. Respiratory sounds are transmitted more readily.
Assessing children Medical Officer must be notified immediately For paediatrics only
The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Paediatric Advanced Clinical Nurses.
Pulse oximetryPulse oximetry should not replace clinical assessment but is a useful adjunct to patient assessment. An age and site appropriate pulse oximetry probe must
be correctly positioned in order to ensure an accurate
reading. Typical paediatric sites are the finger, toe, pinna
(top) or lobe of the ear. Infant sites are the foot or palm
of the hand and the big toe or thumb. Immobile sites are
preferred in wiggling children (eg foot, palm of hand).
RememberWhile pulse oximetry is generally considered a safe
intervention, device limitations and false- positive/
negative results may lead to delayed or inappropriate
treatment. As with all assessments, it is important that
oxygen saturation is considered in terms of the total
clinical picture and not in isolation. Treatment should
never be delayed for a child who looks unwell but who
has an oximetry reading (or any vital sign measure)
within a normal range.
It is important that the oximetry probe is resited at least every two hours, due to the risk of pressure necrosis to the skin.
Oxygen therapyOxygen therapy is recommended to maintain oxygen
saturation (SpO2) greater than 94%.
A Medical Officer must be notified when a child requires
oxygen (O2) and if there are any changes to those
requirements.
When required appropriate delivery systems that may be
chosen and implemented include:
Paediatric non-rebreather bag and mask – for
children requiring high flow oxygen. The reservoir
bag must remain inflated and the oxygen flow rate
regulated so that the bag will only deflate by one third
on inspiration. Requires a minimal oxygen flow rate of
10 litres per minute. The bag must be pre-inflated with
oxygen before placing the mask on the child.
Simple face mask – available in two sizes and
appropriate for moderate to high oxygen flow rates.
Requires a minimum flow rate of at least 6 litres per
minute to effectively clear expired gases, however this is
dependent upon the child’s individual tidal volume.
Disposable infant head box – for infants requiring
oxygen where other methods of oxygen delivery are
not suitable. The headbox is placed over the infant and/
or the head of an infant lying in the supine position. To
ensure adequate carbon dioxide washout, the minimum
oxygen flow rate into the hood is 10 litres per minute.
Checking of oxygen concentration within the hood with
an oxygen analyser if available is desirable to confirm
oxygen content within the hood.
Bag-valve-mask – for children requiring assistance/
positive pressure ventilation. Use age appropriate bag
size. Minimum flow rate is 10 litres per minute. Ensure
valve is opening with breathing.
Low flow nasal prongs – Available in four sizes and
appropriate for conscious children requiring low flow
oxygen to maintain oxygen saturations. Maximum flow
rate is 3 litres per minute. Low flow nasal prongs are not
suitable for acutely unwell children as they cannot deliver
high rates of oxygen.
Refer to Appendix 3 for further information on paediatric
Assessing children Medical Officer must be notified immediately For paediatrics only
The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Paediatric Advanced Clinical Nurses.
Differences Implications
Larger total circulating blood volume per kilogram of body weight than adults.
(Eg Infants have a blood volume of 80 mL/kg).
A relatively small amount of blood loss can be significant eg a 100 mL haemorrhage in a one-year-old child constitutes a loss of approx. 7-10% of the total circulating blood volume.
Higher basal metabolic rate - 2 to 3 times that of adults. Further demands are made by illness.
Vital signs are only one indication of a child’s circulatory status and can only be correctly interpreted within the context of a full physical assessment.
Normal Paediatric Ranges
Age – Years weight – Kg HR/min RR/min
less than 30 days 3.5 100-160 30-60
6 months 7 100-160 30-40
1 10 100-160 30-40
2 12 90 -140 20-40
4 16 90 -140 20-40
6 20 80 -120 20-30
8 24 80 -120 20-30
10 30 80 -120 20-30
greater than 12 40+ 60 -100 15-20
Expected Systolic Blood Pressure = 85+ (age in yrs x 2) mmHg
NSW Health Between The Flags, Standard Paediatric Observation Charts 2010
Heart rate: although there is no strong evidence for this, values measured 10% outside the normal range should be
considered as moderately severe and values 20% outside the normal range considered severe. Interpretation must
always occur in the context of the child’s activity level.
Blood Pressure The normal systolic blood pressure for a child older than
1 year can be calculated using the above formula. Use of
the correct sized blood pressure cuff is crucial. The cuff
width must be 2/3 the length of the upper arm or thigh.
RememberBradycardia is an ominous sign in children and indicates
cardio-respiratory collapse.
Hypotension is a late and pre terminal sign of circulatory
Assessing children Medical Officer must be notified immediately For paediatrics only
The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Paediatric Advanced Clinical Nurses.
When considering vital signs within “normal range” it is important to remember that these should always be considered in relation to the presenting problem and not in isolation. For example, a febrile child would be expected to be tachycardic/tachypnoeic, and a “normal” heart or respiratory rate would warrant close observation and further review. Similarly, significant tachycardia under any circumstance should also be investigated, while bradycardia in any child is an ominous sign and requires immediate medical review and intervention.
Capillary refill time measured centrally on the sternum
(not peripherally ie fingers and toes) also provides a
good indication of circulatory status. Using a thumb,
apply pressure to the sternum for 5 seconds. Capillary
refill should be equal to or less than 2 seconds. A slower
response indicates poor perfusion.
Fluid and electrolytes
Children have Implications
High percentage of total body weight is water.
Greatest percentage of fluid located in the extracellular compartment.
A relatively small amount of fluid loss can lead to
circulatory collapse as adequate intracellular fluids
cannot be drawn on to support the circulatory system.
Large surface area to body weight ratio – greater insensible fluid losses.
Insensible fluid losses are influenced by illness, and
are increased further if the child is febrile, tachypnoeic,
or tachycardic.
High metabolic rate.
Illness increases the already high metabolic rate and as
a result insensible fluid loss. This in turn increases fluid
requirements.
Immature renal function.
Less efficient in excreting waste, concentrating or
diluting urine, and conserving sodium in times of fluid
loss or overload.
Increased fluid requirements per kg of body weight. Greater amount of fluid per kilogram of body weight is required than for the older child or adult.
Signs of dehydration
Mild (3%) Moderate (5%) Severe (10%)
Same as no clinical signs of dehydration plus
Same as mild plus
Lethargy
Tachycardia
Reduced skin turgor
Sunken eyes
Abnormal respiratory pattern
Same as moderate plus
Dry mucous Membranes
Poor perfusion – mottled, cool
limbs/slow capillary refill/altered
consciousness
Mild Tachycardia
Shock - thready peripheral pulses with
marked tachycardia and other signs of
poor perfusion stated above
Source: NSW Health PD2010_009 Infants and Children: Acute Management of Gastroenteritis
Assessing children Medical Officer must be notified immediately For paediatrics only
The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Paediatric Advanced Clinical Nurses.
The following table is a summary of the key developmental phases during childhood and offers some practical
suggestions for your nursing practice.
Age Strategies to minimise anxiety in the ED
Infant
(less than 1 year)
Minimise separation from primary carer.
Use objects familiar to child.
Soothing gentle approach.
Use distraction techniques.
Prepare primary carer and encourage them to soothe and comfort the infant.
Toddler
(1-3 years)
Encourage toddlers to participate in choices.
Where possible maintain routine.
Allow loud protest to procedures.
Gently restrain by wrapping or holding during procedures.
Explain procedures immediately prior to them occurring and provide age appropriate explanations.
Avoid separation from primary carers where possible.
Provide praise.
Preschooler
(3-5 years)
Provide age appropriate accurate information.
Minimise separation from parents/primary carer.
Provide choices (when possible).
Age appropriate explanations.
Procedural play – allow the child to handle equipment.
Use puppets, dolls etc.
Allow verbalisation of fears and feelings.
School age
(5-12 years)
Include parents/primary carer.
Include the child in their care.
Explain procedures in advance.
Use models, drawings explanations.
Provide privacy.
Allow them to verbalise their fears and ask questions.
Adolescents
(13-15 yrs)
Encourage choices and decisions in care.
Realistic and honest explanations.
Models and diagrams used in explanations.
Provide and respect privacy.
Include the parents but consider adolescents needs and requests.
Encourage questions and clarifications.
Adapted from Colizza D, Prior M, and Green P. 1996, The Emergency Department Experience: The Developmental and Psychological Needs of Children. Topics in Emergency Medicine 18: 3. 27-40.
Recognition of a sick child Medical Officer must be notified immediately For paediatrics only
The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Paediatric Advanced Clinical Nurses.
Assessment Intervention
Position Position of comfort with carer
Airway Assess patency Maintain airway patency
Stabilise the C-spine with in-line immobilisation
(if there is a possibility of injury)
Breathing Respiratory rate and effort
SpO2
Auscultation
Assist ventilation if required
Apply O2 via a non-rebreather mask to maintain SpO2 greater than 94%
Circulation Skin temperature
Pulse – Rate/Rhythm
Capillary refill (sternum)
Blood pressure
Cardiac monitor
Colour
IV cannulation/IO needle insertion/pathology
If shocked: tachycardic, bradycardic, hypotensive, prolonged cap refill or mottled skin, give IV/IO 0.9% Sodium Chloride 20 mL/kg bolus
Monitor vital signs frequently
Disability AVPU/GCS + pupils
BGL
Monitor LOC frequently
Finger prick BGL
If less than 3.5 mmol/L administer IV/IO 10% Glucose at 2.5 mL/kg stat. If no IV/IO access available administer IM Glucagon; 0.5 mg stat for a child less than 25kg; IM Glucagon 1 mg stat for a child greater than 25kg
Monitor finger prick BGL every 15 minutes until within normal limits
Measure and test
Pathology
Pain score (1-3)
Pain score (4-6)
Pain score (7-10)
Temperature
U/A (clean catch)
Fluid input/output
Collect blood for FBC, UEC, BGL and blood culture. Consider group and hold in trauma patients
Oral Paracetamol 15 mg/kg stat. Single dose never to exceed 1gm and no more than 4gm in 24 hours.
Oral Oxycodone 0.1 mg/kg (maximum dose 5 mg) stat
IV/IO Morphine 0.1 mg/kg (repeat once in 10 minutes if necessary) to a maximum dose of 10 mg) OR If child greater than 10kg consider Intranasal Fentanyl 1.5 microgram/kg 5 minutely (titrated to pain and sedation) (maximum 75 micrograms total dose)
Per axilla
Collect urine for culture and analysis
Investigate hydration status
Fluid balance chart
Specific treatment
SpO2 Apply O2 to maintain SpO2 greater than 94%
Apply high flow O2 (10-15 litres/min) via a paediatric non-rebreather mask
Document assessment findings, interventions and responses in the patient’s healthcare record
Airway Emergencies Medical Officer must be notified immediately For paediatrics only
The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Paediatric Advanced Clinical Nurses.
Assessment Intervention
PositionDo not allow child to stand or walk. If breathing is difficult allow them to sit in position of comfort with carer.
Cease/remove causative agent
Airway Assess patency
Stridor
Maintain airway patency
If stridor present give IM *Adrenaline 0.01mL/kg of 1:1,000 stat: If symptoms not reversed Adrenaline may be given every 5 minutes as needed.
**If hoarse voice present also consider nebulised Adrenaline 0.5 mL/kg of 1:1,000 stat (maximum 5 mL undiluted) If symptoms not reversed second dose may be given 10 minutes after initial dose
Hoarse voice and/or difficulty talking
Breathing Respiratory rate and effort
SpO2
Wheeze
If patients cannot inhale adequately to use an MDI and spacer or requires oxygen therapy
Assist ventilation if required
Apply O2 to maintain SpO2 greater than 94%.
Apply high flow O2 (10-15 litres/min) via a paediatric non-rebreather mask
If wheeze present give IM *Adrenaline 0.01mL/kg of 1:1,000 stat if symptoms not reversed Adrenaline may be given every 5 minutes as needed.
If wheeze present give Salbutamol: child less than 20kg 6 puffs Salbutamol 100 micrograms dose MDI + spacer stat; child greater than 20kg 12 puffs Salbutamol 100 micrograms dose MDI + spacer stat
Child less than 20kg 2.5 mg Salbutamol nebule stat; child greater than 20kg 5 mg Salbutamol nebule stat. Give via nebuliser mask at a minimum oxygen flow rate of 8 litres/min
Circulation Skin colour
Pulse – rate/rhythm
Blood pressure
Capillary refill
Cardiac monitor
If signs of shock give IM Adrenaline 0.01mL/kg of 1:1000 stat if symptoms not reversed Adrenaline may be repeated every 5 minutes as needed.
IV cannulation/IO needle insertion
If shocked: tachycardic, bradycardic, hypotensive, prolonged capillary refill or mottled skin, give IV/IO 0.9% Sodium Chloride 20 mL/kg bolus
Monitor vital signs frequently
Disability AVPU/GCS + pupils Monitor LOC frequently
Measure and test
Temperature
Fluid input/output
Per axilla
Fluid balance chart
Specific treatment
No response to IM Adrenaline and patient presents with signs of cardio respiratory collapse
IV/IO ***Adrenaline 0.1mL/kg of 1:10,000 Follow paediatric Basic Life Support algorithm
Document assessment findings, interventions and responses in the patient’s healthcare record
Airway Emergencies Medical Officer must be notified immediately For paediatrics only
The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Paediatric Advanced Clinical Nurses.
Drug Dose Route Frequency
Oxygen 10 -15 litres/min Inhalation Continuous
*Adrenaline 0.01mL/kg of 1:1,000 IM Stat. If symptoms not reversed Adrenaline may be repeated every five minutes as needed.
** Adrenaline 0.5 mL/kg of 1:1,000 (maximum 5 ml undiluted) Nebuliser Stat. If symptoms not reversed second dose may be given 10 minutes after initial dose
*** Adrenaline 0.1mL/kg of 1:10,000 IV/IO Consider if cardio respiratory arrest
Salbutamol Child less than 20kg; 6 puffs of 100 microgram dose = (600 micrograms)
Child greater than 20kg; 12 puffs of 100 microgram dose = (1200 micrograms)
Metered dose inhaler via spacer
Stat then repeat as required
Salbutamol Child less than 20kg; 2.5 mg nebule
Child greater than 20kg; 5 mg nebule
Inhalation
Nebuliser with a minimum oxygen flow rate of 8 litres per minute
Child less than 20kg; 2.5 mg nebule stat
Child greater than 20kg; 5 mg nebule stat
0.9% Sodium Chloride
20 mL/kg bolus IV/IO Bolus
0.9% Sodium Chloride
2 mL flush IV/IO As required
Medication standing orders Always check for allergies and contraindications.
The weight of a child is mandatory for calculating drug and fluid doses prior to administration
Precautions and notes.n *Adrenaline 10 micrograms/kg of 1:1,000 IM
equates to Adrenaline 0.01 mL/kg of 1:1,000 IM.
n **Nebulised Adrenaline is not recommended as
first-line therapy, but may be a useful adjunct to IM
Adrenaline if upper airway obstruction is present
n ***Adrenaline 10 micrograms/kg of 1:10,000 IV/IO
equates to Adrenaline 0.1mL/kg of 1:10,000 IV/IO
n For effective salbutamol delivery to the bronchial tree
the oxygen flow rate should be set at 8 litres per
Airway Emergencies Medical Officer must be notified immediately For paediatrics only
The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Paediatric Advanced Clinical Nurses.
Assessment Intervention
Position Position of comfort with carer
Airway Assess patency
Severe croup
Maintain airway patency
Keep child calm
Minimise interventions
Give nebulised Adrenaline 0.5 mL/kg of 1:1,000 stat (maximum 5 mL undiluted). If symptoms not reversed second dose may be given 10 minutes after initial dose then oral *Dexamethasone 0.3 mg/kg stat OR if unable to tolerate oral medication give nebulised Budesonide 2 mg stat
Breathing Respiratory rate and effort
SpO2
Mild
Moderate
Severe
Assist ventilation if required
Apply O2 to maintain SpO2 greater than 94%.
Apply high flow O2 (10-15 litres/min) via a paediatric non-rebreather mask
Continuous monitoring
No specific treatment
*Oral Dexamethasone 0.3 mg/kg stat OR if unable to tolerate oral medication nebulised Budesonide 2 mg stat
Nebulised Adrenaline 0.5 mL/kg of 1:1,000 stat (maximum 5 ml undiluted) repeat at 10 minutes if required plus *Oral Dexamethasone 0.3 mg/kg stat or nebulised Budesonide 2 mg stat if unable to tolerate oral medication
Do not disturb child unnecessarily
Circulation Skin temperature
Pulse – rate/rhythm
Capillary refill
Colour
Monitor vital signs frequently but do not disturb child unnecessarily
Disability AVPU/GCS Monitor LOC frequently
Keep child calm, minimise interventions
Specific treatment
Severe croup only Give nebulised Adrenaline 0.5 mL/kg of 1:1,000 stat (maximum 5 mL undiluted) If symptoms not reversed second dose may be given 10 minutes after initial dose
Document assessment findings, interventions and responses in the patient’s healthcare record
If life-threatening activate your local rapid response protocol immediately
Airway Emergencies Medical Officer must be notified immediately For paediatrics only
The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Paediatric Advanced Clinical Nurses.
Clinical severity prompts
n Child seizing on arrival to the ED
n Unresponsive to pre-hospital treatment
n Seizure lasting greater than five (5) minutes
n Altered level of consciousness
n Inability to maintain own airway
History prompts
n Onset
n Events – mechanism of injury
n Fever/current febrile illness
n Associated symptoms:
– altered level of consciousness, pale, sweaty,
incontinence
n Relevant past history
n Medication history
n Allergies
Assessment Intervention
Position
Position of comfort with carer
Do NOT restrain the patient
Lie supine/left lateral (after tonic phase and clonic movements cease)
Keep carer at hand
Airway Assess patency Maintain airway patency
Consider oro or naso pharyngeal airway
Stabilise the C-spine with in-line immobilisation (if there is a possibility of injury)
Breathing Respiratory rate and effort
Assist ventilation if required
Apply O2 to maintain SpO2 greater than 94%
Apply high flow O2 (10-15 litres/min) via a paediatric non-rebreather mask
Stop the seizures
Buccal Midazolam 0.3 mg/kg (to a maximum of 10mg) stat and repeat (once only) after 5 minutes if required OR
IM/IV/IO Midazolam 0.15 mg/kg stat and repeat (once only) after 5 minutes if required
It may be difficult to adequately manage the patient’s airway and breathing until the seizures have been stopped. Once this has occurred, it will be necessary to reassess/treat/maintain the patient’s airway and breathing.
Circulation Skin temperature
Pulse – rate/rhythm
Capillary refill
Blood pressure (post ictal)
Cardiac monitor
IV cannulation/IO needle insertion/pathology
If shocked: tachycardic, bradycardic, hypotensive, prolonged cap refill or mottled skin, give IV/IO 0.9% Sodium Chloride 20 mL/kg bolus
Airway Emergencies Medical Officer must be notified immediately For paediatrics only
The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Paediatric Advanced Clinical Nurses.
Assessment Intervention
Disability AVPU/GCS + pupils reactivity post ictal
BGL
Monitor LOC frequently
Measure GCS post ictal
Finger prick BGL
If less than 3.5 mmol/L administer IV/IO 10% Glucose at 2.5 mL/kg stat. If no IV/IO access available administer IM Glucagon; child less than 25kg 0.5 mg stat; child greater than 25kg 1 mg stat
Monitor finger prick BGL every 15 minutes until within normal limits
Measure and test
Pathology
Temperature
U/A (clean catch)
Fluid input/output
Collect blood for FBC, UEC, Calcium, Magnesium, Blood Culture
Collect urine for culture and analysis
Nil by mouth
Fluid balance chart
Specific treatment
Stop the seizures Buccal Midazolam 0.3 mg/kg (to a maximum of 10mg) stat and repeat (once only) after 5 minutes if required OR IM/IV/IO Midazolam 0.15 mg/kg stat (to a maximum dose of 5mg) and repeat (once only) after 5 minutes if required
Document assessment findings, interventions and responses in the patient’s healthcare record
Medication standing orders Always check for allergies and contraindications.
The weight of a child is mandatory for calculating drug and fluid doses prior to administration
Drug Dose Route Frequency
Oxygen 10-15 litres/min Inhalation Continuous
10% Glucose 2.5 mL/kg IV/IO Stat
Glucagon hydrochloride Child less than 25kg; 0.5mg
Child greater than 25kg; 1mgIM Stat
Midazolam 0.15 mg/kg (to a maximum dose of 5mg)
IM/IV/IO Stat and repeat (once only) after 5 minutes if required
Midazolam 0.3 mg/kg (to a maximum of 10mg)
BuccalStat and repeat (once only) after 5 minutes if required
Airway Emergencies Medical Officer must be notified immediately For paediatrics only
The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Paediatric Advanced Clinical Nurses.
Assessment Intervention
Disability AVPU/GCS + pupils
BGL
Possible opiate overdose (characterised by pin point pupils and hypoventilation)
Monitor LOC frequently
If GCS less than 9 and not rapidly improving, the patient will require endotracheal intubation by a MO to protect the airway from aspiration
Consider oro-pharyngeal airway, airway opening manoeuvres and bag –valve mask to assist ventilation
Finger prick BGL
If less than 3.5 mmol/L administer IV/IO 10% Glucose at 2.5 mL/kg stat. If no IV/IO access available administer IM Glucagon; child less than 25kg; 0.5 mg stat; child greater than 25kg; 1 mg stat
Monitor finger prick BGL every 15 minutes until within normal limits
If opiate overdose give IV/IO/IM Naloxone 0.1 mg/kg/dose (maximum 2 mg) repeat as necessary
Measure and test
Pathology
Temperature
U/A
Fluid input/output
Collect blood for FBC, UEC, Blood cultures, consider toxicology, (consider group and hold in trauma patients)
Nil by mouth
Specific treatment
Possible opiate overdose (characterised by pin point pupils and hypoventilation)
If opiate overdose give IV/IO/IM Naloxone 0.1 mg/kg/dose (maximum 2 mg) repeat as necessary.
Document assessment findings, interventions and responses in the patient’s healthcare record
Medication standing ordersAlways check for allergies and contraindications.
The weight of a child is mandatory for calculating drug and fluid doses prior to administration.
Drug Dose Route Frequency
Oxygen 10-15 litres/min Inhalation Continuous
10% Glucose 2.5 mL/kg IV/IO Stat
Glucagon hydrochloride Child less than 25kg; 0.5 mg Child greater than 25kg; 1 mg IM Stat
Naloxone 0.1 mg/kg/dose (maximum 2 mg) IV/IO/IM Stat repeat as necessary.
If life-threatening activate your local rapid response protocol immediately
Breathing Emergencies Medical Officer must be notified immediately For paediatrics only
The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Paediatric Advanced Clinical Nurses.
If life-threatening activate your local rapid response protocol immediately
Clinical severity prompts
n Correspond with either mild, moderate, severe or life-
threatening scale as described below
n Representation within 24 hours
n Pre hospital treatment
n Inability to maintain own airway
History prompts
n Onset
n Associated symptoms
n Relevant past history
n Medication history
n Trigger factors
n Past presentation/s admission/s (ICU/HDU/intubation)
n Allergies
n Age less than 12 months (exclude differential diagnosis)
n Parental concern
n Immunisation status
Clinical manifestations of acute Asthma
Mild Moderate *Severe *Life-threatening
Altered consciousness
No No Agitated Agitated, confused, drowsy
Accessory muscle use
No Minimal Moderate Severe
Oximetry in air Greater than 94% 90-94% Less than 90% Less than 90%
Talks in Sentences Phrases Words Words/Unable to talk
Pulse rate Normal for age Tachycardia Marked tachycardia Marked tachycardia or bradycardia#
Central cyanosis No No Likely to be present Likely to be present
Wheeze on auscultation
Variable Moderate-loud Often quiet Often quiet
Physical exhaustion
No No Yes Yes
Modified from: the National Asthma Council Asthma Management Handbook, 2006.* Any of these features indicate the episode is severe or life-threatening. The absence of any feature does not exclude a severe or life-threatening attack.# Bradycardia may be seen when respiratory arrest is imminent.
Breathing Emergencies Medical Officer must be notified immediately For paediatrics only
The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Paediatric Advanced Clinical Nurses.
Assessment Intervention
PositionSit upright
Position of comfort with carer
Airway Assess patency
If the patient shows signs of asthma associated with anaphylaxis (exhibits decreasing LOC, increasing cyanosis of lips/mouth and bradycardia)
Maintain airway patency
If the patient has asthma associated with anaphylaxis give IM *Adrenaline 0.01mL/kg of 1:1,000 stat (one dose only)
Breathing Respiratory rate and effort
SpO2
Use of accessory muscles
Mild asthma
Moderate asthma
If patient cannot inhale adequately to use an MDI and spacer or require oxygen therapy
Severe asthma
Life-threatening asthma
Assist ventilation if required
Apply O2 to maintain SpO2 greater than 94%
Apply high flow O2 (10-15 litres/min) via a paediatric non-rebreather mask
Child less than 20kg; 6 puffs Salbutamol 100 micrograms MDI + spacer stat; child greater than 20kgs; 12 puffs Salbutamol 100 micrograms MDI + spacer stat
**Consider oral Prednisolone 1 mg/kg stat
Child less than 20kg; 6 puffs Salbutamol 100 micrograms MDI + spacer 3 x 20 minutely; Child greater than 20kgs; 12 puffs Salbutamol 100 micrograms MDI + spacer 3 x 20 minutely
Oral Prednisolone 1 mg/kg stat
Child less than 20kg; 2.5 mg Salbutamol nebule 3 x 20 minutely; Child greater than 20kg; 5 mg Salbutamol nebule 3 x 20 minutely. Give via nebuliser mask at a minimum oxygen flow rate of 8 litres/min
Give inhaled Salbutamol continuous nebulised therapy. Give inhaled Ipratropium Bromide at the same time if available
Salbutamol: Load 4 mL of undiluted salbutamol nebule into nebuliser and aim for cannister to be 1/2 to 2/3 full at all times
Ipratropium Bromide:
Child less than 20kg; 250 micrograms 3 x 20 minutely; Child greater than 20kg; 500 micrograms 3 x 20 minutely
Oral Prednisolone 1 mg/kg stat or if oral not tolerated IV/IO Methylprednisolone 1 mg/kg stat
Give inhaled Salbutamol continuous nebulised therapy. Give inhaled Ipratropium Bromide at the same time if available
Salbutamol:
Load 4 mL of undiluted 0.5% Salbutamol Solution into nebuliser and top up as required
Ipratropium Bromide:
Child less than 20kg; 250 micrograms 3 x 20 minutely; Child greater than 20kg; 500 micrograms 3 x 20 minutely
IV/IO Hydrocortisone 4mg/kg OR Methylprednisolone 1 mg/kg stat
Circulatory Emergencies Medical Officer must be notified immediately For paediatrics only
The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Paediatric Advanced Clinical Nurses.
PAGE 45
Assess for RESPONSE
Open and clear AIRWAY — Position head with chin lift or jaw thrust
Assess BREATHING — Look / Listen / FeelIf patient unresponsive and not breathing normally then GIVE 2 RESCUE BREATHS
Attach monitor/DEFIBRILLATOR as soon as possible ASSESS RHYTHM
Assess CIRCULATION – Commence COMPRESSIONS ifa pulse is not palpable within 10 seconds or less than 60 beats/min
and the patient is unresponsive and not breathing normally.15 compressions : 2 breaths
Compression rate 100 beats/min Compression depth 1/3 of the chest wallHand position: lower half sternum
Paediatric ‘Basic’ Life Support Flow Chart for Healthcare Providers
DR
A
B
C
D
Check for DANGER — Hazards / Risks / Safety
SEND (or call) for helpS
Adapted from the ‘Resus4Kids’ Paediatric Advanced Life Support for Health Care Providers flow charts based on the Australian Resuscitation Council Advanced Life Support for Infants and Children Guideline 12.3 December, 2010
Circulatory Emergencies Medical Officer must be notified immediately For paediatrics only
The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Paediatric Advanced Clinical Nurses.
Assessment Intervention
Position Position of comfort with carer
Airway Assess patency Maintain airway patency
Breathing Respiratory rate and effort
SpO2
Assist ventilation if required
Apply O2 to maintain SpO2 greater than 94%
Apply high flow O2 (10-15 litres/min) via a paediatric non-rebreather mask
Circulation Skin temperature
Mild
Moderate
(not shocked)
Severe
Pulse – rate/rhythm
Capillary refill
Cardiac monitor
Colour
IV cannulation/IO needle insertion/pathology - severe dehydration
*Trial of oral fluids 0.5 mL/kg every 5 minutes
*Trial of oral fluids 0.5 mL/kg every 5 minutes
If shocked: tachycardic, bradycardic, hypotensive, prolonged capillary refill or mottled skin, give IV/IO 0.9% Sodium Chloride 20 mL/kg bolus
Monitor vital signs frequently
Disability AVPU/GCS
BGL
Monitor LOC frequently
Finger prick BGL
If less than 3.5 mmol/L administer IV/IO 10% Glucose at 2.5 mL/kg stat. If no IV/IO access available administer IM Glucagon; child less than 25kg; 0.5 mg stat; child greater than 25kg; 1 mg stat
Monitor finger prick BGL every 15 minutes until within normal limits
Measure and test
Pathology
U/A (clean catch)
Fluid input/output
Collect blood for UEC, BGL.
Consider FBC
Collect urine for culture and analysis
Fluid balance chart
Specific treatment
Severe dehydration
Signs of shock
To reduce vomiting a one off dose of oral Ondansetron may be considered
If shocked: tachycardic, bradycardic, hypotensive, prolonged capillary refill or mottled skin, give IV/IO 0.9% Sodium Chloride 20 mL/kg bolus
Oral Ondansetron 0.2 mg/kg stat (Single dose, maximum 8 mg)
Document assessment findings, interventions and responses in the patient’s healthcare record
Circulatory Emergencies Medical Officer must be notified immediately For paediatrics only
The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Paediatric Advanced Clinical Nurses.
Assessment Intervention
Disability AVPU/GCS + pupils
BGL
Monitor LOC frequently
Finger prick BGL
If less than 3.5 mmol/L administer IV/IO 10% Glucose at 2.5 mL/kg stat. If no IV/IO access available administer IM Glucagon; child less than 25kg 0.5 mg stat; child greater than 25kg 1 mg stat
Monitor finger prick BGL every 15 minutes until within normal limits
Measure and test
Pathology
Temperature
U/A (clean catch)
Fluid input/output
Blood loss/PV loss
Collect pathology for Blood Culture, venous pH, FBC, UEC, group and hold
Collect urine for culture and analysis
Urine hCG post-menarchal females
Fluid balance chart
Consider In-dwelling catheter and hourly urine measurement
Nil by mouth
Monitor
Specific treatment
Fluid resuscitation IV cannulation/IO needle insertion x 2, pathology.
If shocked: tachycardic, bradycardic, hypotensive, prolonged capillary refill or mottled skin, give IV/IO 0.9% Sodium Chloride 20 mL/kg bolus
Document assessment findings, interventions and responses in the patient’s healthcare record
Drug Dose Route Frequency
Oxygen 10 -15 litres/min Inhalation Continuous
10% Glucose 2.5 mL/kg IV/IO Stat
Glucagon hydrochloride Child less than 25kg; 0.5 mg Child greater than 25kg; 1 mg
IM Stat
0.9% Sodium Chloride 20 mL/kg IV/IO Bolus
0.9% Sodium Chloride 2 mL flush IV/IO As required
Medication standing ordersAlways check for allergies and contraindications.
The weight of a child is mandatory for calculating drug and fluid doses prior to administration
Disabilities Medical Officer must be notified immediately For paediatrics only
The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Paediatric Advanced Clinical Nurses.
Assessment Intervention
DO NOT DELAY ANTIBIOTIC ADMINISTRATION (See Therapeutic Guidelines)
Disability AVPU/GCS + pupils
BGL
Seizures
Monitor LOC frequently
Finger prick BGL
If less than 3.5 mmol/L administer IV/IO 10% Glucose at 2.5 mL/kg stat. If no IV/IO access available administer IM Glucagon; child less than 25kg; 0.5 mg stat; child greater than 25kg; 1 mg stat
Monitor finger prick BGL every 15 minutes until within normal limits
Buccal Midazolam 0.3 mg/kg stat (maximum dose of 10mg) and repeat (once only) after 5 minutes if required OR IM/IV/IO Midazolam 0.15 mg/kg stat (to a maximum dose of 5mg) and repeat (once only) after 5 minutes if required
Measure and test
Pathology
Temperature
U/A (clean catch)
Fluid input/output
Collect blood for FBC, UEC, BGL, blood cultures
Monitor
Collect urine for culture and analysis
Nil by mouth
Fluid balance chart
Specific treatment
Non-blanching petechial/ purpuric rash or the unwell child with a high index of suspicion for bacterial meningitis
Early administration of steroids to children greater than 3 months who have NOT been pre treated with antibiotics has shown to reduce severe hearing loss by 60%
Urgently contact MO
Urgently administer antibiotics
n 0-3 months IV/IO Ampicillin 50 mg/kg (maximum 2 g) stat or IV/IO Benzyl penicillin 60 mg/kg (maximum 2.4g) stat plus IV/IO Cefotaxime 50 mg/kg (maximum 2 g) stat (slow push over 5 - 10 minutes)
n 3 months - 15 years IV/IO Cefotaxime 50 mg/kg (maximum 2 g) stat or IV/IO Ceftriaxone 50mg/kg/dose (maximum 2 g) stat (slow push over 5 - 10 minutes)
*Greater than 3 months IV/IO Dexamethasone 0.15 mg/kg
(maximum 4 mg) stat - immediately prior to the administration of 1st dose of antibiotics
Document assessment findings, interventions and responses in the patient’s healthcare record
Envenomation/Poisoning Emergencies Medical Officer must be notified immediately For paediatrics only
The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Paediatric Advanced Clinical Nurses.
Assessment Intervention
Disability AVPU/GCS + pupils
BGL
Possible opiate overdose (characterised by pin point pupils and hypoventilation)
Seizures
Contaminant on skin, eyes, clothing
Monitor LOC frequently
If GCS less than 9 and not rapidly improving, the patient may require endotracheal intubation by a MO to protect the airway from aspiration
Finger prick BGL
If less than 3.5 mmol/L administer IV/IO 10% Glucose at 2.5 mL/kg stat. If no IV/IO access available administer IM Glucagon; child less than 25kg; 0.5 mg stat; child greater than 25kg; 1 mg stat
Monitor finger prick BGL every 15 minutes until within normal limits
If opiate overdose give IV/IO/IM Naloxone 0.1 mg/kg (maximum 2 mg) repeat as necessary
Buccal Midazolam 0.3 mg/kg (to a maximum dose of 10mg) stat and repeat (once only) after 5 minutes if required OR
IM/IV/IO Midazolam 0.15 mg/kg stat (to a maximum dose of 5mg) and repeat (once only) after 5 minutes if required
Remove contaminant (ensure safety of patient and staff member – follow protocols)
Measure and test
Pathology
Temperature
U/A
Fluid input/output
Collect pathology for FBC, UEC, toxicology venous blood gas
Collect urine for drug screen if unexplained symptoms exist
Fluid balance chart
Specific treatment
Presentation within one hour of ingestion (and conscious)
Contact Poisons Information Centre 131 126
Oral/nasogastric Activated charcoal 1 g/kg stat (maximum 50 g)
Document assessment findings, interventions and responses in the patient’s healthcare record
Trauma Emergencies Medical Officer must be notified immediately For paediatrics only
The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Paediatric Advanced Clinical Nurses.
Assessment Intervention
Circulation Skin temperature
Blistering
Pulse – rate/rhythm
Capillary refill
Blood pressure
Cardiac monitor
Constrictive non adhered clothing or jewellery
IV cannulation/IO needle insertion x 2 /pathology
If shocked: tachycardic, bradycardic, hypotensive, prolonged cap refill or mottled skin, give IV/IO 0.9% Sodium Chloride 20 mL/kg bolus PLUS for burns greater than 10% TBSA use Modified Parkland formula for fluid replacement (Appendix 8)
Continuous cardiorespiratory monitor (especially for electrical burns and lightning strikes)
Monitor vital signs frequently
Remove
Disability AVPU/GCS + pupils
BGL
Monitor LOC frequently
Finger prick BGL
Measure and test
Primary survey
Pain score (1-3)
Pain score (4-6)
Pain score (7-10)
Secondary survey
Pathology
Temperature
U/A
Fluid input/output
Assess TBSA
Burns greater than 10% TBSA
Repeat
Oral Paracetamol 15 mg/kg stat. Single dose never to exceed 1gm and no more than 4gms in 24 hours.
Oral liquid Oxycodone 0.1mg/kg (maximum 5mg) stat
IV/IO Morphine 0.1 mg/kg (repeat once in 10 minutes if necessary to a maximum dose of 10mg) OR if child greater than 10kg consider Intranasal Fentanyl 1.5 microgram/kg 5 minutely (titrated to pain and sedation) (maximum 75 micrograms total dose)
Non pharmacological measures must be considered early – supportive and distractive techniques Commence
Collect blood for FBC, UEC, BGL, (consider group and hold, myoglobin, ABG/venous blood gas)
Avoid hypothermia
Ward U/A
Monitor – maintain UO at 2 mL/kg/hour Fluid balance chart
Calculate total body surface area burnt
Use paediatric burns assessment chart
Nil orally if burns TBSA greater than 10-15%
For burns greater than 10% TBSA, consider indwelling catheter to measure and record urine output every hour
Modified Parkland formula (see appendix 8): in the first 24 hours post burn give IV/IO Compound Sodium Lactate (Hartmann’s) solution 4mL x kg body weight x % TBSA burnt. Give 50% of total amount first 8 hours from time of burn; give the remaining 50% over the next 16 hours
Trauma Emergencies Medical Officer must be notified immediately For paediatrics only
The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Paediatric Advanced Clinical Nurses.
Assessment Intervention
Specific treatment
Liquid chemical
Powder chemical
Electrical/lightning strike
Circumferential burns
Burn wounds
Gastrointestinal care
Immunisation status
Copious water irrigation
Brush off prior to copious water irrigation. Staff must use Personal Protective Equipment
Maintain UO greater than 2 mL/kg/hour
Elevate the affected limb above the level of the heart. Perform neurovascular observations every 15 minutes
If transferring within 8 hours wrap the burns with cling wrap. If the face is burnt paraffin ointment should be applied
If there is a delay in transfer wound management should be in consultation with the burn surgeon who will receive the patient or with NETS. Do not use Silver Sulphadiazine (SSD) cream without consulting the tertiary burns service and do not apply to the face
Patients with major burns must remain nil by mouth until after consultation with the appropriate burns unit
Check immunisation status and consider tetanus immunisation requirements when patient stable
Document assessment findings, interventions and responses in the patient’s healthcare record
Trauma Emergencies Medical Officer must be notified immediately For paediatrics only
The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Paediatric Advanced Clinical Nurses.
Medications within this guideline must be administered within the context of the formulary.n Medical Officer review is required as soon as
possible. At the time of this review, the Medical
Officer must check and countersign the nurse’s
record of administration on the medication chart as
per NSW Health PD2013_043.
n If a Paediatric Advanced Clinical Nurse uses these
clinical guidelines, a Medical Officer will be notified
immediately to ensure their early involvement with
the management and care of the patient.
Precautions and notesn Consult with burns specialist (or NETS) early.
n Children have different body surface area
proportions: Use the Paediatric Rule of Nines, and adjust for age by taking 1% BSA from the
head and adding ½% BSA to each leg for each year
of life after 1 year until 10 years.(Adult proportions
are reached at 10Yrs.) (Refer to Appendix 8)
n For ongoing fluid management in children,
maintenance fluids should be added to the fluid
calculated with the Modified Parkland Formula.
n Do not use ice to cool burn.
n Be cautious in administration of Morphine if there
is an altered level of consciousness, respiratory
Authorising Medical Officer signature:
Name:
Designation:
Date:
Drug Committee approval:
Date:
compromise or hypotension. Use of sedation
scores may be beneficial in reassessment.
n Refer to burn injury Referral/Retrieval Criteria Checklist; Burns Transfer Flow Chart; Burn Patient Emergency Assessment and Management Chart; Assessment of Total Body Surface Area (TBSA) and Burn Distribution; Resuscitation Fluids (Refer Appendix 8)
n Children who have completed a full primary
immunisation course no greater than 5 years ago will
not require further immunisation.
n Individuals who have no documented history of
receiving a primary vaccination course (3 doses)
of tetanus toxoid – containing vaccines should
receive a complete primary course. Please refer to
Primary Vaccination in The Australian Immunisation
Handbook 11th Edition January 14.
ReferencesMackway-Jones K. Molyneux E. Phillips B. Wieteska
S. [ED] 2005, Advanced Paediatric Life Support, The
Practical Approach. 4th edn. The burned or scalded child,
pp 199-204 BMJ Blackwell Publishing Group Limited,
Massachusetts.
MIMS Australia 2013. MIMS Annual 37th edn. St
Leonards.
NSW Health GL2012_003 Rural Adult Emergency Clinical
Trauma Emergencies Medical Officer must be notified immediately For paediatrics only
The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Paediatric Advanced Clinical Nurses.
Assessment Intervention
Breathing Respiratory rate and effort
SpO2
Wheeze
If patient cannot inhale adequately to use an MDI and spacer and requires oxygen
Auscultation
Assist ventilation if required
Apply O2 to maintain SpO2 greater than 94%
Apply high flow O2 (10-15 litres/min) via a paediatric non-rebreather mask
If SpO2 falls below 94% with O2 consult MO
If wheeze present give inhaled Salbutamol:
Child less than 20kg; 6 puffs Salbutamol 100 micrograms MDI + spacer stat; Child greater than 20kg; 12 puffs Salbutamol 100 micrograms MDI + spacer stat
Child less than 20kg; 2.5 mg Salbutamol nebule stat;
Child greater than 20kg; 5 mg Salbutamol nebule stat. Give via nebuliser mask at a minimum oxygen flow rate of 8 litres/min
Consider risk of pneumothorax, especially if rapid ascent from a significant depth
Circulation Skin temperature
Pulse – rate/rhythm
Capillary refill
Blood pressure
Cardiac Monitor
Colour
Remove wet clothing – cover with blankets, (passive warming). Do NOT actively rewarm unless < 34°C
IV cannulation/IO needle insertion /pathology
If shocked: tachycardic, bradycardic, hypotensive, prolonged capillary refill or mottled skin, give IV/IO 0.9% Sodium Chloride 20 mL/kg bolus
Monitor vital signs frequently
Disability AVPU/GCS + pupils
BGL
Monitor LOC frequently
Finger prick BGL
If less than 3.5 mmol/L administer IV/IO 10% Glucose at 2.5 mL/kg stat. If no IV/IO access available administer IM Glucagon; 0.5 mg stat for a child less than 25kg; IM Glucagon 1 mg stat for a child greater than 25kg
Monitor finger prick BGL every 15 minutes until within normal limits
Measure and test
Pathology
Temperature
U/A
Fluid input/output
Chest x-ray
Collect blood for FBC, UEC, serum glucose, ABG/venous blood gas if available.
Avoid hypothermia
Core temperature if possible
Fluid balance chart
Nil by mouth
Consider In-dwelling catheter and hourly measures
If available
Specific treatment
Gastric distension No attempt should be made to empty the stomach by external pressure. Consider gastric decompression with an oro or nasogastric tube
Document assessment findings, interventions and responses in the patient’s healthcare record
Trauma Emergencies Medical Officer must be notified immediately For paediatrics only
The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Paediatric Advanced Clinical Nurses.
Assessment Intervention
Disability AVPU/GCS + pupils
Low risk
Intermediate risk
High risk
Severe head injury (GCS less than 9)
BGL
Seizures
Monitor LOC frequently
If GCS less than 9 and not rapidly improving, the patient will require endotracheal intubation by a MO to protect the airway from aspiration.
Consider oro-pharyngeal airway, airway opening manoeuvres and bag –valve mask to assist ventilation
May be discharged after medical review. Hourly observations until discharge.
Half hourly observations for 4-6 hours until GCS 15 is sustained for 2 hours, then hourly observations until discharge
Consider transfer
CT scan if acute deterioration or persisting symptoms (Refer Appendix 9)
Continuous cardiorespiratory and oxygen saturation monitoring
BP and GCS every 15-30 minutes
Urgent CT
Transfer/retrieval
Trauma call-retrieval to nearest paediatric referral centre
Finger prick BGL
If less than 3.5 mmol/L administer IV/IO 10% Glucose at 2.5 mL/kg stat. If no IV/IO access available administer IM Glucagon; 0.5 mg stat for a child less than 25kg; IM Glucagon 1 mg stat for a child greater than 25kg
Monitor finger prick BGL every 15 minutes until within normal limits
Buccal Midazolam 0.3 mg/kg (maximum dose 10mg) stat and repeat (once only) after 5 minutes if required ORIM/IV/IO Midazolam 0.15mg/kg (to a maximum dose of 5mg) stat and repeat (once only) after 5 minutes if required
Measure and test
Pathology
Primary survey
Secondary survey
Neurological observations
Temperature
U/A
Fluid input/output
Pain score (1-3)
Pain score (4-6)
Pain score (7-10)
Collect blood for FBC, UEC (consider drug/alcohol blood levels)
Repeat
Commence
Monitor frequently
Protect from hypo/hyperthermia
Test for presence of blood
Fluid balance chart
Nil by mouth if decreasing level of consciousness
GCS 14 or 15 and patient not nil by mouth
Oral Paracetamol 15 mg/kg stat Single dose never to exceed 1gm and no more than 4gms in 24 hours.Oral liquid Oxycodone 0.1 mg/kg (maximum dose 5mg)
IV/IO Morphine 0.1 mg/kg (repeat once in 10 minutes if necessary to a maximum dose of 10 mg) OR Intranasal **Fentanyl 1.5 microgram/kg 5 minutely (titrated to pain and sedation) (maximum 75 micrograms/kg)
Non pharmacological measures must be considered early-supportive and distractive techniques
Trauma Emergencies Medical Officer must be notified immediately For paediatrics only
The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Paediatric Advanced Clinical Nurses.
Medication standing ordersAlways check for allergies and contraindications.
The weight of a child is mandatory for calculating drug and fluid doses prior to administration
Drug Dose Route Frequency
Oxygen 10 -15 litres/min Inhalation Continuous
Paracetamol
Precaution: Prior to administration determine recent administration of any medicines containing Paracetamol (minimum dosing interval is 4 hours).
Dose is recommended for patients of normal or average build.*15mg/kg/dose 4th hourly to a maximum of 60mg/kg/day.
Single dose never to exceed 1gm and no more than 4gms in 24 hours.
Oral Stat
10% Glucose 2.5 mL/kg IV/IO Stat
Glucagon hydrochloride Child less than 25kg; 0.5 mg Child greater than 25kg; 1 mg
IM Stat
Midazolam 0.15 mg/kg (to a maximum dose of 5mg)
IM/IV/IOStat and repeat (once only) after 5 minutes if required
Midazolam 0.3 mg/kg (to a maximum dose of 10mg)
BuccalStat and repeat (once only) after 5 minutes if required
Oxycodone 0.1 mg/kg (maximum 5 mg) Oral Stat
**Fentanyl1.5 microgram/kg (maximum 75 micrograms total dose)
Intranasal5 minutely (titrated to pain and sedation)
Morphine sulphate 0.1 mg/kg IV/IOStat.(repeat once in 10 minutes if necessary to a maximum dose of 10 mg)
Assessment Intervention
Specific treatment
Severe High risk
Severe head injury
Seizures
Refer for urgent CT
Trauma call
Buccal Midazolam 0.3 mg/kg (to a maximum dose of 10mg) stat and repeat (once only) after 5 minutes if required ORIM/IV/IO Midazolam 0.15mg/kg (to a maximum dose of 5mg) stat and repeat (once only) after 5 minutes if required
Document assessment findings, interventions and responses in the patient’s healthcare record
* Refer to NSW Health PD2009_009 Paracetamol Use for other patients
If life-threatening activate your local rapid response protocol immediately
Other Emergencies Medical Officer must be notified immediately For paediatrics only
The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Paediatric Advanced Clinical Nurses.
Clinical severity prompts
n Signs of shock
n Bile stained vomiting
n Bloody stool
n Distension
n Localised tenderness to right upper or lower quadrant
of abdomen
n Inguinoscrotal pain or swelling
n Rapid onset
History prompts
n Nature of onset
n Parental concern
n Associated symptoms
– nature of pain/radiation
– nausea, vomiting
– diarrhoea
– last menstrual period/symptoms of pregnancy
– urinary symptoms
– weight loss
n Relevant past history
n Immunocompromised
n Medication history
n Events – mechanism of injury (if trauma involved)
n Allergies
n Immunisation status
Assessment Intervention
Position Position of comfort with carer
Airway Assess patency Maintain airway patency
Breathing Respiratory rate and effort
SpO2
Assist ventilation if required if required
Apply O2 to maintain SpO2 greater than 94%
Apply high flow O2 (10-15 litres/min) via a paediatric non-rebreather mask
Circulation Skin temperature
Pulse – rate/rhythm
Capillary refill
Blood pressure
Colour
IV cannulation/IO needle insertion/pathology
If shocked: tachycardic, bradycardic, hypotensive, prolonged cap refill or mottled skin, give IV/IO 0.9% Sodium Chloride 20 mL/kg bolus
Monitor vital signs frequently
Disability AVPU/GCS
BGL
Monitor LOC frequently
Finger prick BGL
If less than 3.5 mmol/L administer IV/IO 10% Glucose at 2.5 mL/kg stat. If no IV/IO access available administer IM Glucagon; child less than 25kg 0.5 mg stat; child greater than 25kg 1 mg stat
Monitor finger prick BGL every 15 minutes until within normal limits
Other Emergencies Medical Officer must be notified immediately For paediatrics only
The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Paediatric Advanced Clinical Nurses.
Assessment Intervention
Measure and test
Abdominal assessment
Pain score (1-3)
Pain score (4-6)
Pain score (7-10)
Pathology
Temperature
U/A (clean catch)
Fluid input/output
Look, listen feel
Oral Paracetamol 15 mg/kg stat if not nil by mouth.
Single dose never to exceed 1gm and no more than 4gms in 24 hours.
Oral liquid Oxycodone 0.1 mg/kg (max dose 5mg)
IV/IO Morphine 0.1 mg/kg IV/IO (repeat once in 10 minutes if necessary to a maximum dose of 10 mg) OR Intranasal Fentanyl 1.5 microgram/kg 5 minutely (titrated to pain and sedation) 75 micrograms total dose
Non pharmacological measures must be considered early – supportive and distractive techniques
Collect blood for FBC, UEC, (consider LFT’s, amylase, coags, group and hold)
Collect urine for culture and analysis, Urine hCG
Fluid balance chart
Specific treatment
Hydration/input
Nausea and vomiting
Nil by mouth
Record and report - fluid balance chart
Document assessment findings, interventions and responses in the patient’s healthcare record
Poisoning with; strong acid, alkali, Iron sulfate, other Iron salts, cyanides, sulfonylureas including tolbutamide, malathion, dicophane (clofenotane), Li, ethanol, methanol, ethylene glycol, hydrocarbons, lithium, iron compounds, potassium and other metallic ions, fluoride, hydrocarbons.
Unprotected airway. Decreased LOC, GI tract not intact, significant fluid, electrolyte abnormalities. Do not give repeat doses or to infants less than 1 year.
Interactions Oral medications
Pregnancy
Activated charcoal is not absorbed from the gastrointestinal tract and is not expected to pose a risk to the fetus during pregnancy. However, the cathartic effect of sorbitol may cause diarrhoea resulting in electrolyte disturbances or dehydration. Should be used during pregnancy only when necessary. The potential risk to the fetus of both the poisoning and the treatment need to be balanced against the risk of failing to detoxify the mother.
PrecautionsCentral Nervous System depression, GIT disturbances and recent surgery, children 1 to 11 years, diarrhoea may lead to electrolyte disturbance
Indications/Doses Anaphylactic reaction 0.01mL/kg 1:1,000 IM Stat. If symptoms not reversed, Adrenaline may be given every 5 minutes as needed.
Asthma 0.01mL/kg 1:1,000 IM Stat. If symptoms not reversed, Adrenaline may be given every 5 minutes as needed.
Cardiorespiratory Arrest (Advanced Life Support) 0.1mL/kg of 1:10,000 IV/IO every 4 minutes
Croup 0.5 mL/kg (undiluted) nebulised 1:1,000 to a maximum of 5 mL
Contraindications
Interactions
Sympathomimetics cause additive effects. Beta blockers antagonise therapeutic effects of Adrenaline; digitalis potentiates proarrhythmic effects of Adrenaline; tricyclic antidepressants; Monoamine Oxidase Inhibitors potentiate cardiovascular effects of Adrenaline; phenothiazine causes a paradoxical decrease in blood pressure.
Pregnancy
Category A
Drugs which have been taken by a large number of pregnant women and women of childbearing age without any proven increase in the frequency of malformations or other direct or indirect harmful effects on the fetus having been observed. Adrenaline may delay the second stage of labour by inhibiting contractions of the uterus.
Precautions
Adverse effects include cardiac ischaemia or dysrhythmias, fear, anxiety, tremor, and hypertension with subarachnoid haemorrhage; use with caution in hypertension, cardiovascular disease, and cerebrovascular insufficiency; phenothiazines can cause a paradoxical decrease in blood pressure comment as above
Indications/DosesCardiorespiratory Arrest (Advanced Life Support)
5 mg/kg/dose IV/IO (maximum 300 mg/dose) stat (Dilute with 5%Glucose)
ContraindicationsDocumented history of hypersensitivity; systemic lupus erythematosus, digitalis induced dysrhythmias, torsade de pointes, second or third degree heart block (without pacemaker) symptomatic bradycardia (without pacemaker) or sick sinus syndrome.
Interactions
Increases effect and blood levels of theophylline, quinidine, procainamide, phenytoin, methotrexate, flecanide, digoxin, cyclosporine, beta-blockers and anti coagulants; and disopyramide increases cardiotoxicity; co-administration with calcium channel blockers may cause additive effects, further decreasing myocardial contractility; cimetidine may increase amiodarone levels.
Pregnancy
Category C
Drugs that, owing to their pharmacological effects, have caused or may be suspected of causing harmful effects on the human fetus or neonate without causing malformations. These effects may be reversible. Avoid use 3 months before and during pregnancy; may cause thyroid dysfunction and bradycardia in the fetus.
PrecautionsHypotension (most common adverse effect), bradycardia, and Atrio-Ventricular block may occur. Phlebitis is an issue. Incompatible with 0.9% Sodium Chloride. Overly rapid administration can cause hypotension.
Infants 0-3 months old 50 mg/kg IV/IO stat (maximum 2 g) per dose infuse slowly.
Contraindications History of hypersensitivity to beta-lactam antibiotics
Interactions Gentamicin
Pregnancy
Category A
Drugs which have been taken by a large number of pregnant women and women of childbearing age without any proven increase in the frequency of malformations or other direct or indirect harmful effects on the fetus having been observed
PrecautionsSerious, and occasionally fatal, hypersensitivity reactions (anaphylaxis) have been reported in patients receiving beta-lactam antibiotics.
Infants 0-3 months old 60 mg/kg IV/IO stat (maximum 2.4 g) per dose infuse slowly.
Contraindications History of hypersensitivity reactions to beta-lactam antibiotics.
Interactions
Intravenous solutions of benzylpenicillin are physically incompatible with many other substances including certain antihistamines, some other antibiotics, metaraminol tartrate, noradrenaline acid tartrate, thiopentone sodium and phenytoin sodium, may effect glucose in urinalysis
Pregnancy
Category A
Drugs which have been taken by a large number of pregnant women and women of childbearing age without any proven increase in the frequency of malformations or other direct or indirect harmful effects on the fetus having been observed
PrecautionsSerious, and occasionally fatal, hypersensitivity reactions (anaphylaxis) have been reported in patients receiving beta-lactam antibiotics.
Contraindications Known history of hypersensitivity to Budesonide
Interactions Ketoconazole and Itraconazole can increase systemic exposure to budesonide. This is of limited clinical importance for short-term (one to two weeks) treatment with CYP3A inhibitors, but should be taken into consideration during long-term treatment.
Pregnancy
Category A
Drugs which have been taken by a large number of pregnant women and women of childbearing age without any proven increase in the frequency of malformations or other direct or indirect harmful effects on the fetus having been observed
PrecautionsBudesonide is not indicated for rapid relief of bronchospasm. Pulmicort is, therefore, not suitable as sole therapy for the treatment of status asthmaticus or other acute exacerbations of asthma where intensive measures are required.
Children greater than 3 months old 50 mg/kg IV/IO stat (maximum 2 g) per dose
Contraindications Allergy to the cephalosporins
Interactions Chloramphenicol. Ceftriaxone is incompatible with calcium; do not give via calcium containing solutions i.e do not mix with Hartmann’s
Pregnancy
Category B1
Drugs that have been taken by only a limited number of pregnant women and women of childbearing age, without an increase in the frequency of malformation or other direct or indirect harmful effects on the human fetus having been observed. Studies in animals [1] have not shown evidence of an increased occurrence of fetal damage.
PrecautionsRenal, hepatic impairment; vitamin K synthesis; prolonged use; history of GI disease (esp colitis); pregnancy; lactation
Drug Name Compound Sodium Lactate (Hartmann’s Solution)
Indications/DosesBurns
IV/IO as per Parkland formula
ContraindicationsClinical states adversely affected by sodium, severe impairment of renal function, lactic acidosis, congestive cardiac failure
Interactions Administration via the same line as blood products may lead to coagulation. Concomitant administration with potassium sparing diuretics and angiotensin (ACE inhibitors) may cause severe hyperkalaemia.
Pregnancy
Category C
Drugs that, owing to their pharmacological effects, have caused or may be suspected of causing harmful effects on the human fetus or neonate without causing malformations. These effects may be reversible.
Suspected Bacterial Meningitis in children greater than 3 months of age0.15 mg/kg IV/IO stat
Contraindications Uncontrolled infections. Known hypersensitivity to dexamethasone
Interactions Rifampicin, phenytoin and barbiturates may reduce the plasma levels and half-life of corticosteroids. Oral contraception.
Pregnancy
Category A
Drugs which have been taken by a large number of pregnant women and women of childbearing age without any proven increase in the frequency of malformations or other direct or indirect harmful effects on the fetus having been observed
Precautions Live vaccines, cirrhosis or hypothyroidism may enhance the effect of corticosteriods
Indications/DosesRecognition of the Sick Baby and ChildIf IV access unavailable:n Children greater than 25kg; 1mg IM stat if BGL less than 3.5 mmol/Ln Children less than 25kg; 0.5 mg IM stat if BGL less than 3.5 mmol/L
SeizuresIf IV access unavailable: n Children greater than 25kg; 1mg IM stat if BGL less than 3.5 mmol/L n Children less than 25kg; 0.5 mg IM stat if BGL less than 3.5 mmol/L
Unconscious patient If IV access unavailable: n Children greater than 25kg; 1mg IM stat if BGL less than 3.5 mmol/L n Children less than 25kg; 0.5 mg IM stat if BGL less than 3.5 mmol/L
Gastroenteritis If IV access unavailable: n Children greater than 25kg; 1mg IM stat if BGL less than 3.5 mmol/L n Children less than 25kg; 0.5 mg IM stat if BGL less than 3.5 mmol/L
Shock If IV access unavailable: n Children greater than 25kg; 1mg IM stat if BGL less than 3.5 mmol/L n Children less than 25kg; 0.5 mg IM stat if BGL less than 3.5 mmol/L
Suspected bacterial meningitis If IV access unavailable: n Children greater than 25kg; 1mg IM stat if BGL less than 3.5 mmol/L n Children less than 25kg; 0.5 mg IM stat if BGL less than 3.5 mmol/L
PoisoningIf IV access unavailable: n Children greater than 25kg; 1mg IM stat if BGL less than 3.5 mmol/L n Children less than 25kg; 0.5 mg IM stat if BGL less than 3.5 mmol/L
DrowningIf IV access unavailable: n Children greater than 25kg; 1mg IM stat if BGL less than 3.5 mmol/L n Children less than 25kg; 0.5 mg IM stat if BGL less than 3.5 mmol/L
Head injuryIf IV access unavailable: n Children greater than 25kg; 1mg IM stat if BGL less than 3.5 mmol/L n Children less than 25kg; 0.5 mg IM stat if BGL less than 3.5 mmol/L
Abdominal pain If IV access unavailable: n Children greater than 25kg; 1mg IM stat if BGL less than 3.5 mmol/L n Children less than 25kg; 0.5 mg IM stat if BGL less than 3.5 mmol/L
Interactions May enhance the effects of anticoagulants
Pregnancy
Category B2
Drugs that have been taken by only a limited number of pregnant women and women of childbearing age, without an increase in the frequency of malformation or other direct or indirect harmful effects on the human fetus having been observed. Studies in animals[1] are inadequate or may be lacking, but available data show no evidence of an increased occurrence of fetal damage
Australian Medicines Handbook http://amh.hcn.com.au/ <accessed 06/03/14>
Australian Injectable Drugs Handbook, Fourth Edition http://aidh.hcn.com.au/index.php <accessed 06/03/14>
NSW Health PD2010_009 Infants and Children: Acute Management of Gastroenteritis
NSW Health PD2011_038 Recognition of a Sick Baby or Child in the Emergency Department
NSW Health PD2013_044 Infants and Children: Acute Management of Bacterial Meningitis
NSW Health PD2013_053 Infants and Children: Acute Management of Abdominal Pain
NSW Health PD2009_065 Infants and Children: Acute Management of Seizures
NSW Health PD2011_024 Infants and Children: Acute Management of Head Injury
NSW Health GL2012_003 Rural Adult Emergency Clinical Guidelines 3rd Edition Version 3.1 http://www0.health.nsw.gov.au/policies/gl/2012/GL2012_003.html <accessed 06/03/14>
Drug Name Glucagon Hydrochloride
PrecautionsGlucagon will have little or no effect if patient is fasting or suffering from adrenal insufficiency, chronic hypoglycaemia or alcohol induced hypoglycaemia.
Indications/Doses Seizures 2.5 mL/kg IV/IO stat if BGL less than 3.5 mmol/L
Unconscious patient 2.5 mL/kg IV/IO stat if BGL less than 3.5 mmol/L
Gastroenteritis 2.5 mL/kg IV/IO stat if BGL less than 3.5 mmol/L
Shock 2.5 mL/kg IV/IO stat if BGL less than 3.5 mmol/L
Suspected bacterial meningitis 2.5 mL/kg IV/IO stat if BGL less than 3.5 mmol/L
Poisoning 2.5 mL/kg IV/IO stat if BGL less than 3.5 mmol/L
Drowning 2.5 mL/kg IV/IO stat if BGL less than 3.5 mmol/L
Head injury 2.5 mL/kg IV/IO stat if BGL less than 3.5 mmol/L
Abdominal pain 2.5 mL/kg IV/IO stat if BGL less than 3.5 mmol/L
Contraindications Avoid in dehydrated patients in a diabetic (hyperglycaemic) coma
Interactions Do not administer simultaneously with blood products via the same infusion line
Pregnancy
Category C
Drugs that, owing to their pharmacological effects, have caused or may be suspected of causing harmful effects on the human fetus or neonate without causing malformations. These effects may be reversible
Precautions
May cause nausea, monitor fluid balance, electrolyte concentrations, and acid-base balance closely. Glucose administration may produce vitamin B-complex deficiency. Thrombophlebitis.
Drug Name Hydrocortisone sodium succinate (Solu-Cortef)
Indications/DosesSevere and life-threatening asthma
4 mg/kg IV/IO stat
ContraindicationsKnown hypersensitivity, systemic fungal infections; premature infants; live attenuated vaccines.
Interactions
Thiazide diuretics may increase the risk of hyperglycaemia caused by hydrocortisone. Rifampicin, phenytoin and barbiturates may reduce the plasma levels and half-life of corticosteroids. Decreases the efficiency of the following medications; Aspirin, Insulin, oral anti-diabetic medication, oral contraceptive pill
Pregnancy
Category C
Drugs that, owing to their pharmacological effects, have caused or may be suspected of causing harmful effects on the human fetus or neonate without causing malformations. These effects may be reversible
Precautions Cirrhosis or hypothyroidism may enhance the effect of corticosteroids
Indications/DosesSevere and life-threatening asthma
Child less than 20kg; 250 micrograms 3 x 20 minutely via nebuliser. Child greater than 20kg; 500 micrograms 3 x 20 minutely via nebuliser
Contraindications Documented hypersensitivity to ipratropium
Interactions
Drugs with anticholinergic properties may increase toxicity. Cardiovascular effects may increase with Monoamine Oxidase Inhibitors, tricyclic antidepressants and sympathomimetic agents. Disodium cromoglycate inhalation solutions containing benzalkonium chloride. Beta-Adrenergics and xanthine
Pregnancy
Category B1
Drugs that have been taken by only a limited number of pregnant women and women of childbearing age, without an increase in the frequency of malformation or other direct or indirect harmful effects on the human fetus having been observed. Studies in animals have not shown evidence of an increased occurrence of fetal damage.
PrecautionsCaution in glaucoma (protect eyes if nebuliser in use), hyperthyroidism, diabetes mellitus, cardiovascular disorders and cystic fibrosis. May cause bronchoconstriction in some patients with hyper reactive airways
The sedative effects of neuroleptic, tranquillizers, antidepressants, sleep inducing drugs, analgesics, anaesthetics, antipsychotics, anxiolytics, antiepileptic drugs and sedative antihistamines may be enhanced by the administration of midazolam. Pre medication, alcohol and barbiturates may increase the sedative effect of midazolam.
Pregnancy
Category C
Drugs that, owing to their pharmacological effects, have caused or may be suspected of causing harmful effects on the human fetus or neonate without causing malformations. These effects may be reversible.
PrecautionsRespiratory depression, apnoea, cardiovascular depression and cardiac arrest. Pharmacokinetics in children has not been established in children less than 8 years and may differ from adults.
Indications/Doses Recognition of a sick child 0.1 mg/kg IV/IO (repeat once in 10 minutes if necessary to a maximum dose of 10mg)
Burns (if pain score 4-10) 0.1 mg/kg IV/IO (repeat once in 10 minutes if necessary to a maximum dose of 10mg)
Head injury (if pain score 4-10) 0.1 mg/kg IV/IO (repeat once in 10 minutes if necessary to a maximum dose of 10mg)
Abdominal pain (if pain score 4-10) 0.1 mg/kg IV/IO (repeat once in 10 minutes if necessary to a maximum dose of 10mg)
Contraindications Documented hypersensitivity; severe respiratory disease, coma.
Interactions Respiratory depressant and sedative effects may be additive toxicity in the presence of other medication.
Pregnancy
Category C
Drugs that, owing to their pharmacological effects, have caused or may be suspected of causing harmful effects on the human fetus or neonate without causing malformations. These effects may be reversible.
PrecautionsCaution in hypotension, nausea, vomiting, supraventricular tachycardia; has vagolytic action and may increase ventricular response rate. Caution in patients with severe renal, hepatic dysfunction, may cause excessive sedation or coma.
Indications/Doses Unconscious patient 0.1mg/kg/dose (maximum 2 mg) IV, IO, IM, Sub Cutaneous, repeat as necessary
Poisoning 0.1mg/kg/dose (maximum 2 mg) IV, IO, IM, Sub Cutaneous, repeat as necessary
Contraindications Documented hypersensitivity.
Interactions Decreases analgesic effects of opioids. Effects of partial agonists eg buprenorphine, tramadol only partially reversed by naloxone
Pregnancy
Category B1
Drugs that have been taken by only a limited number of pregnant women and women of childbearing age, without an increase in the frequency of malformation or other direct or indirect harmful effects on the human fetus having been observed. Studies in animals have not shown evidence of an increased occurrence of fetal damage
Precautions
Caution in cardiovascular disease; may precipitate withdrawal symptoms in patients with opiate dependence; if patients do not respond to multiple doses of naloxone, consider alternative cause of unconsciousness. Reversal of opioid effects may unmask other toxicities in cases of ingestion of multiple agents and increase the risk of seizures. Be cautious of administration to neonates whose mothers are known or suspected to be addicted to opioids, as it may cause an abrupt and complete reversal of opioid effect and acute withdrawal syndrome
Contraindications Hypersensitivity to any component of the preparation
Interactions May reduce the analgesic effect of tramadol. phenytoin, carbamazepine and rifampicin increase the oral clearance time and reduces the blood concentration of Ondansetron. Avoid the concomitant use of drugs that prolong the QT interval.
Pregnancy
Category B1
Drugs that have been taken by only a limited number of pregnant women and women of childbearing age, without an increase in the frequency of malformation or other direct or indirect harmful effects on the human fetus having been observed. Studies in animals have not shown evidence of an increased occurrence of fetal damage.
Precautions Subacute intestinal obstruction, not recommended in breast feeding
ContraindicationsKnown hypersensitivity to opioid analgesics. CNS depression. Respiratory Depression, raised intra cranial pressure, concomitant monoamine oxidase inhibitors. Children less than 1 year old.
Drugs which, owing to their pharmacological effects, have caused or may be suspected of causing, harmful effects on the human fetus or neonate without causing malformations. These effects may be reversible.
Pregnancy Respiratory depression, hypotension; hypovolaemia; impaired renal or hepatic function
Precautions
Caution in cardiovascular disease; may precipitate withdrawal symptoms in patients with opiate dependence; if patients do not respond to multiple doses of naloxone, consider alternative cause of unconsciousness. Reversal of opioid effects may unmask other toxicities in cases of ingestion of multiple agents and increase the risk of seizures. Be cautious of administration to neonates whose mothers are known or suspected to be addicted to opioids, as it may cause an abrupt and complete reversal of opioid effect and acute withdrawal syndrome
Paracetamol (oral) Drug Category: Analgesic and antipyretic
Drug Name Paracetamol (oral)
Indications/Doses Recognition of the sick childDose is recommended for patients of normal or average build; if not nil by mouth15mg/kg/dose 4th hourly to a maximum of 60mg/kg/day.
Single dose never to exceed 1gm and no more than 4gms in 24 hours.
BurnsDose is recommended for patients of normal or average build; if not nil by mouth15mg/kg/dose 4th hourly to a maximum of 60mg/kg/day.
Single dose never to exceed 1gm and no more than 4gms in 24 hours.
Head injuryDose is recommended for patients of normal or average build; if not nil by mouth15mg/kg/dose 4th hourly to a maximum of 60mg/kg/day.
Single dose never to exceed 1gm and no more than 4gms in 24 hours.
Abdominal painDose is recommended for patients of normal or average build; if not nil by mouth15mg/kg/dose 4th hourly to a maximum of 60mg/kg/day.
Single dose never to exceed 1gm and no more than 4gms in 24 hours.
Contraindications Documented hypersensitivity. Patient is nil orally
Drugs which have been taken by a large number of pregnant women and women of childbearing age without any proven increase in the frequency of malformations or other direct or indirect harmful effects on the fetus having been observed.
PrecautionsPrior to administration determine recent administration of any medicines containing Paracetamol. Caution in severe renal or hepatic dysfunction
Mild 1 mg/kg oral stat-if prolonged episode or a history of severe asthma
Moderate 1 mg/kg oral stat
Severe 1 mg/kg oral stat-if tolerated orally
Croup 1 mg/kg oral stat-if tolerated orally and Dexamethasone unavailable
Contraindications Documented hypersensitivity to Prednisone, Tuberculosis, systemic fungal infection
Interactions Live vaccines (should not use); alcohol; antacids; antidiabetics; diuretics; hepatic enzyme
inducers eg phenytoin and rifampicin; cyclosporin; ketoconazole; anticoagulants.
Pregnancy
Category A
Drugs which have been taken by a large number of pregnant women and women of childbearing age without any proven increase in the frequency of malformations or other direct or indirect harmful effects on the fetus having been observed.
Precautions Patients who are immunosuppressed, live vaccines
Salbutamol sulphate (Ventolin) Drug Category: Bronchodilator
Drug Name Salbutamol sulphate (Ventolin)
Indications/Doses
Anaphylactic reaction
Metered dose inhaler + spacer; n Child less than 20kg; 6 puffs of 100 microgram Metered Dose Inhaler + spacer
stat if wheeze presentn Child greater than 20kg; 12 puffs of 100 microgram Metered Dose Inhaler + spacer
stat if wheeze present
Nebulisern Child less than 20kg; 2.5 mg nebule stat (if patients cannot inhale adequately to use an MDI
and spacer or requires oxygen therapy)n Child greater than 20kg; 5 mg nebule stat (if patients cannot inhale adequately to use an MDI
and spacer or requires oxygen therapy)
Asthma
Mild - Metered Dose Inhaler + spacer n Child less than 20kg 6 puffs of 100 microgram Metered Dose Inhaler + spacer stat n Child greater than 20kg 12 puffs of 100 microgram Metered Dose Inhaler + spacer stat
ModerateMetered Dose Inhaler + spacer n Child less than 20kg; 6 puffs of 100 micrograms Metered Dose Inhaler + spacer
repeat every 20 minutes n Child greater than 20kg; 12 puffs of 100 micrograms Metered Dose Inhaler + spacer
repeat every 20 minutes
Nebulisern Child less than 20kg; 2.5 mg nebule repeat every 20 minutes (if patients cannot inhale
adequately to use an MDI and spacer or requires oxygen therapy)n Child greater than 20kg; 5 mg nebule repeat every 20 minutes (if patients cannot inhale
adequately to use an MDI and spacer or require oxygen therapy)
Severe/life-threateningContinuous nebulisern Load 4 mL of undiluted 0.5% Salbutamol Solution into nebuliser and
top up as required
Drowning n Child less than 20kg; 6 puffs of 100 microgram Metered Dose Inhaler + spacer
stat if wheeze presentn Child greater than 20kg; 12 puffs of 100 microgram Metered Dose Inhaler + spacer
stat if wheeze present
Nebulisern Child less than 20kg; 2.5 mg nebule stat (if patients cannot inhale adequately to use an MDI
and spacer or requires oxygen therapy)n Child greater than 20kg; 5 mg nebule stat (if patients cannot inhale adequately to use an MDI
Contraindications History of hypersensitivity; Can cause paradoxical bronchospasm; allergic reactions
Interactions May increase cardiovascular effects of other sympathomimetics
Pregnancy
Category A
Drugs which have been taken by a large number of pregnant women and women of childbearing age without any proven increase in the frequency of malformations or other direct or indirect harmful effects on the fetus having been observed.
PrecautionsMay cause tachycardia, nausea and tremors. Caution in patients with co-existing cardiovascular disease. Hypokalaemia can occur with high dose particularly in combination with other potassium depleting medications.
Indications/Doses IV/IO Cannula Flush - 2mL Medication dilution - as per medication protocol. Indications/Doses For the following conditions:
Recognition of a sick child IV/IO 20 mL/kg bolus If shocked: tachycardic, bradycardic, hypotensive, prolonged cap refill or mottled skin, capillary refill greater than 2 seconds (centrally)
Anaphylactic reaction IV/IO 20 mL/kg bolus If shocked: tachycardic, bradycardic, hypotensive, prolonged cap refill or mottled skin, capillary refill greater than 2 seconds (centrally)
Seizures IV/IO 20 mL/kg bolus If shocked: tachycardic, bradycardic, hypotensive, prolonged cap refill or mottled skin, capillary refill greater than 2 seconds (centrally)
Unconscious patient IV/IO 20 mL/kg bolus If shocked: tachycardic, bradycardic, hypotensive, prolonged cap refill or mottled skin, capillary refill greater than 2 seconds (centrally)
Cardiorespiratory arrest - Advanced Life Support IV/IO 20 mL/kg bolus If shocked: tachycardic, bradycardic, hypotensive, prolonged cap refill or mottled skin, capillary refill greater than 2 seconds (centrally)
Shock IV/IO 20 mL/kg bolus If shocked: tachycardic, bradycardic, hypotensive, prolonged cap refill or mottled skin, capillary refill greater than 2 seconds (centrally)
Gastroenteritis IV/IO 20 mL/kg bolus If shocked: tachycardic, bradycardic, hypotensive, prolonged cap refill or mottled skin, capillary refill greater than 2 seconds (centrally)
Suspected bacterial meningitis IV/IO 20 mL/kg bolus If shocked: tachycardic, bradycardic, hypotensive, prolonged cap refill or mottled skin, capillary refill greater than 2 seconds (centrally)
Poisoning IV/IO 20 mL/kg bolus If shocked: tachycardic, bradycardic, hypotensive, prolonged cap refill or mottled skin, capillary refill greater than 2 seconds (centrally)
Snake/spider bite IV/IO 20 mL/kg bolus If shocked: tachycardic, bradycardic, hypotensive, prolonged cap refill or mottled skin, capillary refill greater than 2 seconds (centrally)
Burns IV/IO 20 mL/kg bolus If shocked: tachycardic, bradycardic, hypotensive, prolonged cap refill or mottled skin, capillary refill greater than 2 seconds (centrally)
Drowning IV/IO 20 mL/kg bolus If shocked: tachycardic, bradycardic, hypotensive, prolonged cap refill or mottled skin, capillary refill greater than 2 seconds (centrally)
Head injury IV/IO 20 mL/kg bolus If shocked: tachycardic, bradycardic, hypotensive, prolonged cap refill or mottled skin, capillary refill greater than 2 seconds (centrally)
Abdominal pain IV/IO 20 mL/kg bolus If shocked: tachycardic, bradycardic, hypotensive, prolonged capillary refill or mottled skin, capillary refill greater than 2 seconds (centrally)
Febrile neutropaenia CVAD/IV/IO 20 mL/kg bolus If shocked: tachycardic, bradycardic, hypotensive, prolonged cap refill or mottled skin, capillary refill greater than 2 seconds (centrally)
Contraindications
Interactions Amiodarone
Pregnancy
Category A
Drugs which have been taken by a large number of pregnant women and women of childbearing age without any proven increase in the frequency of malformations or other direct or indirect harmful effects on the fetus having been observed.
PrecautionsCongestive cardiac failure, severe renal impairment, sodium retention. Do not use if the solution is not clear.
Adhesive tapes Brown tape ½ inch, or paediatric IV site dressing
Intraosseous Manual or battery operated insertion device with paediatric and adult size needles
OtherECG dots (Paediatric)
Defib pads x 2 packets (Paediatric)
NG tube (size 8Fg, 10Fg, 12Fg)
Paediatric Advanced Life Support algorithm
ReferenceNSW Health PD2010_032 Children and Adolescents – Admission to Services Designated Level 1-3 Paediatric Medicine and Surgery, June 2010
Resuscitation Standards for Clinical Practice and Education Provision Australian Resuscitation Council, Australian Council of Critical Care Nurses http://www.resus.org.au/policy/documents/clinical_standards_for_resuscitation_march08.pdf <accessed 06/03/14>
Heat source Overhead heater or other heat source (optional)
Distraction activities box
Oral use only medication syringes
1mL, 3mL, 5mL, 10mL
Cot / bed with rails in situ Bunny rugs, cot sheet & blankets
Infant formula Disposable bottle & teat, feeding cup
Gastrolyte, Hydrolyte or similar
Ice blocks and solution
Trial of oral fluids chart
Kitchen scales (1g increments)
To weigh nappies
Disposable nappies
ReferenceNSW Health PD2010_032 Children and Adolescents – Admission to Services Designated Level 1-3 Paediatric Medicine and Surgery, June 2010
Resuscitation Standards for Clinical Practice and Education Provision Australian Resuscitation Council, Australian Council of Critical Care Nurses http://www.resus.org.au/policy/documents/clinical_standards_for_resuscitation_march08.pdf <accessed 06/03/14>
This is a systematic approach used for patient assessment
and treatment when the patient has life-threatening
conditions or injuries. The Primary/Secondary Survey
emphasises the importance of prioritising and instigating
the correct sequence of care.
Noten Infants and young children are prone to hypothermia.
Although it is important to expose children for
assessment, it is necessary to provide external heating
like warm blankets/towels or overhead heating
during this procedure.
n Hypothermia in the infant and young child can hasten
or lead to more serious illness.
The Primary Survey consists of a rapid patient
assessment and treatment of any immediately life-
threatening conditions.
This will involve simultaneous assessment and treatment
of the following:
n Airway with cervical spine controln Breathing and ventilationn Circulation and haemorrhage control n Disability – neurologicaln Exposure (undress the patient).
Secondary Survey is a systematic assessment of
the patient from head to toe, so that each body
system is reviewed. It includes patient history
and commencement of relevant investigations.
Using a systematic approach:
n Head and Facen Neckn Chestn Abdomenn Pelvis and Genitalian Upper and Lower Limbsn Backn Vital signsn History – Including mechanism of injury past
and present medical history and relevant family history
n Investigationsn Documentation.
Throughout the Secondary Survey the patient requires
continuous monitoring and assessment, if there is any
deterioration, the Primary Survey should be repeated.
ReferenceSkinner. D, Driscoll. P, Earlam. R. (2000). ABC of Major
Trauma. BMJ. 3rd Edition. Cambridge University Press.
GuidelineTitle: Burn Transfer Guidelines – NSW Severe Burn Injury Service – Second Edition
page 14 of 21
NSW Severe Burn Injury Service Burn Transfer Flow Chart Medical Retrieval Referral Minor Burns
Meets Medical Retrieval • Intubated patients • Head and neck burns • Burns>10% in children or >20% in
adults • Burns with associated inhalation • Burns with significant co-morbidities
e.g. trauma • Electrical/chemical injury • Significant pre-existing medical disorder • Circumferential to limbs or chest
compromising circulation or respiration
Needs referral but not medical retrieval • Burns >5% children or >10% adults• Burns to hands, feet, face,
genitalia, perineum and major joints• Burns with a pre-existing medical
condition eg diabetes • Children with suspected non-
accidental injury & adults with assault, self inflicted injury
• Pregnancy ( 2nd 3rd trimester RNSH)
• Spinal cord injury -RNSH • Extremes of ages
Minor burns are treated in consultation with the referring doctor as an outpatient; either locally (at original place of care) or on referral to an ambulatory burns clinic for assessment.
Contact NETS for children AMRS Adults up to16th birthday 1800 65 0004 1300 36 2500
The Children’s Hospital at Westmead Catchment Area: All children’s referrals to the age of 16 in all areas of NSW
Concord Repatriation General Hospital Catchment Area: South Eastern Sydney/Illawarra, Sydney West, Sydney South West, Greater Southern٭, Greater Western٭, ACT
Catchment Area: North Sydney/Central Coast, Hunter/New England, North Coast٭ ٭refer to Burns Units in adjoining states
CHW: Surgical Registrar on-call notified Tel. 9845 0000 then page Surgical Registrar CRGH: Burns Registrar on-call notified Tel 9767 5000 then page Burns Registrar RNSH: Burns Registrar on-call notified Tel 9926 7111 then page Burns Registrar
Not referred to service
AMRS/NETS will coordinate transfer between primary hospital and the receiving hospital
The on call registrar will offer advice and arrange a bed in liaison with Bed Management and the Burns Unit. They are responsible for receiving the patient. The referrer will make the ambulance booking.
Referred to service
Any issues or problems with these processes or if further advice is required, The NSW Severe Burn Injury Service Manager can be contacted on 02 9926 5641.
Royal North Shore HospitalCatchment Area: NorthSydney/Central Coast, Hunter/NewEngland, North Coast
Hospitals near state border areas mayrefer to Burns Units in adjoining states
Reference NSW Health. 2008. Burns Transfer Guidelines – NSW Severe Burns Injury service. 2nd edn. (GL2008_012).
Burn Mechanism: ________________________________________________________________ ________________________________________________________________________________ First Aid given (as defined below): � NO � YES Specify ___________________________
FIRST AID • At least 20 mins cold running water (8 - 25°C). Effective up to 3 hours post injury.• Protect against hypothermia, keep rest of body warm. Cease cooling if body temp <35°C
PRIMARY SURVEY Airway � Normal � Neck/facial burns with swelling � Burn in confined space � Intubated � Hoarse Voice / Stridor / Cough / Carbonaceous material – mouth / nose / sputum C Spine � Normal � At Risk � Immobilised Breathing RR ___ Air Entry ______ O2 sats ___ FiO2 ___ Effort - normal/shallow/increased Burn circumferential around chest / torso / neck? � Yes � No Circulation HR _____________ BP ________ / _________ Central capillary refill � 1-2 seconds � > 2 seconds � Absent Any circumferential burns? � No � Yes, specify area/s _____________________ Peripheral capillary refill � 1-2 seconds � > 2 seconds � Absent Disability Level of consciousness (AVPU): __________ Pupils: (L) ___ mm (R) ___ mm AVPU = A – Alert, V - Response to Vocal stimuli, P - Responds to Painful stimuli, U - UnresponsiveEnvironment Patient Temp. ____°C @ _____________ (time/date) Temp route ___________ Remove clothing and jewellery Keep unburnt areas warm Warm IV fluids � No � Yes �N/A Warm blankets � No � Yes � N/AAssess % Total Body Surface Area (TBSA) burnt using Rule of Nines (see page 2) TBSA body chart completed? � No � Yes By whom? _______________
Fluid Resuscitation (see page 3 for specific fluid calculations) � Not required Large bore IVCs (2 for >20%, 1 for >10%) or CVL inserted? � No � Yes Bloods taken: � FBC � EUC � BSL � Coags � COHb � Drug screen IDC Inserted? (if % TBSA > 10% or perineum) � No � Yes Nasogastric tube inserted? (if % TBSA > 15%) � No � Yes Co-existing injuries? � Yes � Possible (eg blast / electrical injury) � No Specify ________________________________________________________________________
PAIN MANAGEMENT Morphine is the drug of choice for acute pain following burns. If allergic use appropriate alternative. • Adults Stat IV morphine 2mg, repeat every 5mins as required Max. 0.2mg/kg• Children Stat IV morphine 0.1mg/kg, repeat every 15mins as required Max. 0.3mg/kg• Reassess every 5 minutes and discuss with appropriate medical staff if analgesia insufficient • Minor burn Oral analgesia (eg paracetamol +/- codeine / oxycodone, etc) may be adequate Analgesia given prior to presentation: � No � Yes Specify _____________________________ Pain Score ____________ Time ____ (use age appropriate pain rating scale) Analgesia given ______________ Dose _______ Time _______ Effective � No � Yes
IMMUNISATION Immunisations up to date? � No � Yes Specify __________________________________ Tetanus status: � Primary course given � Give Immunoglobulin if < 3 doses � Last dose of booster _________ � Give booster if last booster > 5yrs ago
GuidelineTitle: Burn Transfer Guidelines – NSW Severe Burn Injury Service – Second Edition
page 17 of 21
RESUSCITATION FLUIDS (if > 10% TBSA for children, >15% for adults)
Weight ________ kg Modified Parkland Formula = 3-4 mls x weight (kg) x % TBSA burn
to be given as Hartmann’s solution in 24hrs following the injury (see Transfer Guidelines) 3-4 mls x ________kg x _________% TBSA = total fluids for 1st 24hrs
* NB This is a guide only - Titrate fluids to urine output*Total resuscitation fluids in 24hrs _______ mls
Start time ______ Finish time _______50% Replacement in 1st 8hrs following injury _______ mls Total Fluid given prior to admission _______ mls Subtract Fluid already given = fluid to be given to complete 1st 8hrs _______ mls Hourly rate for replacement (within 1st 8 hrs) mls/hr
Start time ______ Finish time _______ Remaining 50% of Replacement in next 16hrs _______ mls Hourly rate for replacement (in subsequent 16 hrs) _______ mls/hr
Start time _______ Finish time ______ Maintenance fluids (for children < 30kgs only) _______ mls/hr
MAINTENANCE FLUIDS (Not applicable for adults) Children < 30kg require maintenance fluids (N/2 Saline + 2.5% Dextrose) in addition to resus. fluids.
Up to 10kg 100ml/kg/day 10-20kg 1000mls plus 50ml/kg/day (for each kg >10kg and <20kg)20-30kg 1500mls plus 20ml/kg/day(for each kg > 20kg)
URINE OUTPUT • Children 1ml/kg/hr (range 0.5 – 2ml/kg/hr) • Adults 0.5 – 1 ml/kg/hr • 2ml/kg/hr required for pigmented urine such as myoglobinuria / haemoglobinuria
REFERRAL CRITERIA Refer to Transfer Guidelines (“Referral” meaning contact with not necessarily transfer to Burn Unit)
• Partial/full thickness burns in children >5% TBSA, in adults >10% TBSA. • Any priority areas are involved, i.e. face/neck, hands, feet, perineum, genitalia and major joints. • Caused by chemical or electricity, including lightning. • Any circumferential burn. • Burns with concomitant trauma or pre-existing medical condition. • Burns with associated inhalation injury. • Suspected non-accidental injury. • Pregnancy with cutaneous burns NB All paediatric burns (<16 yrs) fitting any of the above criteria need referral to The Children’s Hospital at Westmead (CHW). Adult burns fitting above criteria need referral to the adult unit at Royal North Shore Hospital (RNSH) or Concord Repatriation General Hospital (CRGH) (dependent on area health service intake area). For contact details see Transfer Guidelines.
DRESSING For transfer to specialist unit within 8 hrs apply cling film to burnt areas (Vaseline gauze/white paraffin for face). Do not wrap circumferentially. For delayed transfer > 8hrs apply antimicrobial dressing such as Vaseline gauze (eg Bactigras) or silver dressing, after discussion with burn unit. For burns not requiring transfer to specialist unit • give pre med analgesia 30mins prior to procedure (eg paracetamol +/ oxycodone, etc) • clean wound with chlorhexidine 0.1%, saline or clean water • apply appropriate dressing such as silver dressing or Vaseline gauze (see Minor Burn Management). Contact Burn
Unit for advice if required. • make follow-up appointment and advise on care and analgesia for home usage and pre-dressing.
Reference NSW Health. 2008. Burns Transfer Guidelines – NSW Severe Burns Injury service. 2nd edn. (GL2008_012).
B – Breathing Respiratory rate, rhythm and depth, work of breathing, oxygen delivery device and amount
C – Circulation Skin colour, warmth and diaphoresis, capillary refill, pulses, overt bleeding, IV cannula (position and size) & fluids, (commence a fluid balance chart if fluids are administered)
D – Disability (neurological)
– Discomfort (pain assessment)
A – alertV – responds to voiceP – responds to painful stimuliU – unresponsive
Pupils size & reaction
(PEARL)
Pain assessmentand score
+ BGL
E – Exposure & Environment
Head-to-toe or focused assessment (identified abnormalities and environmental hazards during exposure)
HISTORY(source – the patient, care giver or Ambulance Officer)
M – mechanism of injury / illness I – injuries sustained / illness progression S – signs & symptoms T – treatment (pre presentation) / transport
ONGOING ASSESSMENTTriage category 1- 3Record vital signs at time of assessment and frequency according to patient clinical presentations
Further mandatory documentation is required according to the patient’s clinical presentation or if the patient is admitted (ie alcohol/other drug use, smoking, skin integrity and falls screening)
Triage category 4 Record vital signs at time of assessment and at least one further set prior to discharge or according to the patient’s clinical presentation
Triage category 5 Record vital signs at time of assessment and relevant to presentation
A – allergiesM – medications (prescription, over the counter, herbal) P – past medical / surgical history L – last meal / last menstrual period / last immunisation E – events leading up to presentation
PLAN What plan has been put in place for this patient?
Document in a concise and clear manner: -– procedures, interventions, outcome & evaluation chronologically– standing orders or guidelines if commenced– notification – who has been told– comply with legal reporting responsibilities
EVALUATION Reassess patient and document outcomes
DISCHARGE – Time of departure– Destination– Referrals
• Document discharge information including any instructions or education given to the patient or family
• If patient not prepared to wait to be seen – document advice given to the patient or family
Further mandatory documentation is required according to the patient’s clinical presentation or if the patient is admitted (ie alcohol/other drug use, smoking, skin integrity and falls screening)