Targeted therapies by presentation
›Wheeze and asthma pathway
›Albuterol nebulized
›Under 20 kg 2.5 mg
›20 kg or greater 5 mg
›Repeat every 20 minutes for 1 hour
›Ipratropium nebulized
›Under 20 kg 0.25 mg
›20 kg or greater 0.5 mg
›Up to 3 doses in first hour
›Systemic corticosteroid
›Dexamethasone PO or IV 0.6 mg per kg
›Maximum 16 mg
›Alternative prednisone or prednisolone PO 1 to 2 mg per kg per day
›Maximum 60 mg per day
›Magnesium sulfate IV
›25 to 50 mg per kg
›Maximum 2 g
›Infuse over 20 to 30 minutes
›Continuous albuterol local protocol dependent
›Typical 10 to 20 mg per hour
›Cardiac monitoring required
›Bronchiolitis pathway
›Nasal suction
›Hydration support
›PO as tolerated
›IV or NG fluids if poor intake
›Oxygen targets local protocol dependent
›Persistent SpO2 below 90 percent
›Apnea monitoring in young infants
›Bronchodilator trial
›Consider in recurrent wheeze history
›Discontinue if no clear benefit
›Croup and upper airway pathway
›Dexamethasone
›0.6 mg per kg PO or IM
›Maximum 16 mg
›Nebulized epinephrine for moderate to severe croup
›Racemic epinephrine 2.25 percent 0.05 mL per kg
›Maximum 0.5 mL
›Dilute to 3 mL with saline
›Alternative L epinephrine 1 mg per mL 0.5 mL per kg
›Maximum 5 mL
›Post epinephrine observation
›Rebound symptoms possible
›Duration local protocol dependent
›Anaphylaxis pathway
›Epinephrine IM
›0.01 mg per kg of 1 mg per mL
›Maximum 0.3 mg in child
›Maximum 0.5 mg in adolescent
›Repeat every 5 to 15 minutes if needed
›Adjuncts
›H1 antihistamine
›Inhaled bronchodilator for wheeze
›IV fluids for shock
›Pneumonia pathway
›Antibiotics when bacterial pneumonia likely
›Outpatient amoxicillin high dose local protocol dependent
›Inpatient ampicillin or ceftriaxone local protocol dependent
›Pleural effusion consideration
›Ultrasound evaluation
›Drainage decision with pediatrics
›Foreign body aspiration pathway
›Avoid blind finger sweeps
›Suspected complete obstruction
›Age appropriate choking algorithm
›Immediate airway team activation
›Suspected partial obstruction
›Minimize agitation
›Bronchoscopy planning
Monitoring and reassessment loop
›Reassessment cadence
›Every 15 to 30 minutes in moderate to severe distress
›After each major intervention
›Trend elements
›Work of breathing
›SpO2 and oxygen requirement
›Heart rate trend
›Mental status trend
›Hydration and perfusion
›Escalation criteria
›Increasing oxygen requirement
›Persistent severe retractions
›Rising CO2 concern on gas or capnography
›Deteriorating mental status
Respiratory support and intubation considerations
›Noninvasive support
›HFNC for hypoxemia with increased work of breathing
›CPAP or BiPAP for fatigue or hypercapnia in select cases
›Intubation indications
›Apnea
›Refractory hypoxemia
›Refractory hypercapnia with fatigue
›Airway protection failure
›Shock requiring airway control
›Intubation pitfalls
›Preoxygenation challenges
›Rapid desaturation in infants
›Dynamic hyperinflation in asthma
›Avoid bagging with high rate in asthma