Acute Gastroenteritis, Adult Emergency Orders

Transcription

1 Form Title Form Number , Alberta Health Services, CKCM This work is licensed under the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License. The license does not apply to content for which the Alberta Health Services is not the copyright owner. To view a copy of this license, visit Disclaimer: This material is intended for use by clinicians only and is provided on an information, Alberta Health Services does not make any representation or warranty, express, a particular purpose of such information. This material is not a substitute for the advice of a of these materials, and for any claims, actions, demands or suits arising from such use.

2 Select orders by placing a ( ) in the associated box Allergies Goals of Care For more information, see Clinical Knowledge Topic - Emergency o Goals of Care Designation: Patient Care Monitoring o Vital Signs: These orders need to be re-evaluated when the patient stabilizes or by two hours, whichever occurs first. o as per provincial guideline o every hourly o every minute(s) o Continuous cardiac monitoring o Isolation: contact precautions (consider if C. difficile infection suspected or confirmed) Diet/Nutrition o NPO o NPO May Have Sips, May Take Meds o Clear Fluid o Regular Diet o Other Diet: Intravenous Fluid Orders (severe cases only) o Intravenous Cannula - Insert: Initiate IV o IV Peripheral Saline Flush/Lock: Saline Lock IV Bolus or rapid infusion o 0.9% sodium chloride infusion ml as fast as possible Maintenance IV o 0.9% sodium chloride infusion at ml/hour o dextrose 5% in water - 0.9% sodium chloride infusion at ml/hour o dextrose 5% in water % sodium chloride infusion at ml/hour o Other (specify fluid) at ml/hour IV Solutions with Potassium o potassium chloride 20 mmol/l in 0.9% sodium chloride infusion at ml/hour; STOP AFTER ONE LITRE o potassium chloride 40 mmol/l in 0.9% sodium chloride infusion at ml/hour; STOP AFTER ONE LITRE o potassium chloride 20 mmol/l in dextrose 5% % sodium chloride at ml/hour; STOP AFTER ONE LITRE o potassium chloride 40 mmol/l in dextrose 5% % sodium chloride at ml/hour; STOP AFTER ONE LITRE o Other: at ml/hour Page 1 of 6

3 Laboratory Investigations Hematology o Complete Blood Count (CBC) and differential o PT / INR Transfusion Medicine o Type and Screen Chemistry o Electrolytes (Na, K, Cl, CO 2 ) o Glucose random level o Bilirubin Total o Alkaline Phosphatase Level (ALP) o GGT o Lactate Blood Gases o Venous blood gas o Arterial blood gas o Creatinine o Urea o Albumin o ALT o Lipase o Blood Glucose Monitoring - POCT Microbiology o Blood Cultures o Stood Bacterial Culture (See Table 1) o C. difficile Toxin assay (See Table 2) o Giardia & Cryptosporidium screen (See Table 3) o Ova and Parasite Examination (See Table 3) Urine Tests o Pregnancy Test, Urine - POCT Other Labs (based on presentation needs of the patient) o o Diagnostic Investigations o Electrocardiogram - 12 Lead Consider for patients presenting with epigastric or substernal pain with radiation, especially in the presence of ACS risk factors. Be particularly aware that diabetic patients may present with atypical ACS and a high index of clinical suspicion is warranted. o X-ray Abdomen, 2 or More Projections indication o X-ray Chest, 1 Projection (component of abdominal X-Ray) Page 2 of 6

4 Medications Antiemetics Avoid dimenhydrinate in patients 65 years of age or older due to increased risk of side effects including delirium. Suggest 25 mg for mild/moderate nausea, 50 mg for moderate/severe nausea dimenhydrinate o dimenhydrinate 50 mg once route o PO o IV o dimenhydrinate 25 to 50 mg PO every 4 hour PRN for nausea and vomiting o dimenhydrinate 25 to 50 mg IV every 4 hour PRN for nausea and vomiting o dimenhydrinate mg o PO o IV PO administration or slow infusion via IVPB are preferred for metoclopramide to reduce the risk of akathisia. Suggest 5 mg for mild/moderate nausea or if CrCl less than 40mL/min; 10 mg for moderate/severe nausea, and CrCl over 40mL/min metoclopramide o metoclopramide 10 mg PO once route o PO o IVPB o metoclopramide 5 to 10 mg PO every 6 hour PRN for nausea and vomiting o metoclopramide 5 to 10 mg IV every 6 hour PRN for nausea and vomiting o metoclopramide mg o PO o IVPB 4 mg starting dose recommended for IV ondansetron ondansetron o ondansetron 4 mg IV once o ondansetron 4 mg IV to be repeated once 30 minutes after first dose PRN for nausea/vomiting o ondansetron every 8 hour PRN for nausea/vomiting route/dosage o 8 mg PO o 4 mg IV o ondansetron mg o PO o IV Due to high cost, recommend reserving ondansetron DISINTEGRATING tab for actively vomiting patients without an IV o ondansetron DISINTEGRATING tab 8 mg PO every 8 hour PRN for nausea/ vomiting Antimotility Agents o ondansetron DISINTEGRATING tab mg PO Use lowest dose possible to avoid post-treatment constipation. Avoid in patients with bloody diarrhea or suspected C. difficile infection loperamide o loperamide 4 mg PO once o loperamide 2 mg PO every 1 hour PRN (if PRN give after each loose bowel movement. MAX 16 mg/day from all sources) Page 3 of 6

5 Medications Continued Antibiotics Empiric use is discouraged in community-acquired gastroenteritis Should be avoided in suspected or proven enterohemorrhagic E. coli (O157:H7) Consider in patients with: Moderate / severe travel-associated diarrhea Persistent (lasting longer than 7 days) or severe (temperature greater than 38.5oC, greater than 6 bloody stools/day, severe abdominal pain) symptoms with positive stool cultures (very severe symptoms may also warrant empiric treatment before cultures done) Typhoidal Salmonella Non-typhoidal Salmonella in immunocompromised patient, age greater than 50 years, bacteremia, or endovascular grafts o ciprofloxacin 500 mg PO every 12 hours first choice for most travellers diarrhea, Shigella enteritis, milder typhoid / paratyphoid Salmonella (unless acquired in SE Asia), high-risk non-typhoidal Salmonella, and severe / prolonged / immunocompromised Yersinia, Aeromonas, Plesiomonas, and non-cholera Vibrio o AZIthromycin 500 mg PO every 24 hours first choice for pregnancy, travelers from southeast Asia and India, severe / prolonged / immunocompro mised Campylobacter enteritis o ceftriaxone 2 g IV every 24 hours first choice in severe/bacteremic typhoid / paratyphoid / nontyphoid Salmonella o doxycycline 300 mg PO once first choice in Vibrio cholera Clostridium difficile (see Table 4 for clinical definitions) Discontinue antibiotics, if possible; if not possible, consider change to lower-clostridium difficile infection risk antibiotics: TMP/SMX, tetracyclines, and/or metronidazole First episode or first recurrence of uncomplicated disease: o metronidazole 500 mg PO TID x 10 days Second recurrence of uncomplicated disease: o vancomycin liquid 125 mg PO QID x 10 days AND THEN vancomycin liquid 125 mg PO every 3 days x 3 weeks Any episode of severe disease OR any episode unresponsive to 3 to 5 days metronidazole therapy: o vancomycin liquid 125 mg PO QID x 10 days Complicated Clostridium difficile infection (Select all) o vancomycin liquid 125 mg PO QID x 10 days o vancomycin liquid 500 mg NG QID x 10 days if unable to tolerate PO o metronidazole 500 mg IV every 8 hours x 10 days o vancomycin enema 500 mg PR every 6 hours Page 4 of 6

6 Medications Continued Antihistamine Consider in scombroid or allergy mediated gastrointestinal symptoms o diphenhydramine 50 mg IV once Nonopiate Analgesia - Oral acetaminophen o acetaminophen1000 mg PO once o acetaminophen 500 to 1000 mg PO every 4 hour PRN for pain (maximum 3000 mg/ day) o acetaminophen tab mg PO Suggest 325 to 650 mg for mild to moderate pain, 975 to 1000 mg for moderate to severe pain Use of antimuscarinics in patients with invasive (bloody) diarrhea and/or C.diff are relatively contraindicated hyoscine o hyoscine 10 mg PO once o hyoscine 10 mg IM/IV once Opiate Analgesia - Oral For susceptible patients defined as elderly, frail, low body mass, systemically unwell, or on medications known to cause sedation or lower blood pressure we recommend decreasing narcotic dosing by 50%. Contact physician or nurse practitioner for reassessment if pain not controlled after administration of maximum dosage. codeine o codeine 30 mg-acetaminophen 325 mg-caffeine 15 mg 2 tabs PO once o codeine 30 mg-acetaminophen 325 mg-caffeine 15 mg 1 to 2 tabs PO every 4 hours PRN for pain o codeine 30 mg-acetaminophen 325 mg-caffeine 15 mg tabs PO oxycodone o oxycodone 5 mg-acetaminophen 325 mg 2 tabs PO once o oxycodone 5 mg-acetaminophen 325 mg 1 to 2 tabs PO every 4 hours PRN for pain o oxycodone 5 mg-acetaminophen 325 mg tabs PO HYDROmorphone o HYDROmorphone 1 mg PO once o HYDROmorphone 1 to 2 mg PO every 4 hour PRN for pain o HYDROmorphone mg PO Suggest 1 mg for moderate pain and 2 mg for severe pain Page 5 of 6

7 Medications Continued Opiate analgesia - Parenteral HYDROmorphone o HYDROmorphone 1 mg IV once o HYDROmorphone 0.5 to 1 mg every 10 minutes PRN for pain (maximum 3 mg total) o HYDROmorphone mg IV Suggest 0.5 mg for moderate pain and 1 mg for severe pain morphine o morphine 5 mg IV once o morphine 2.5 to 5 mg IV every 10 minutes PRN for pain (maximum 15 mg total) o morphine mg IV Suggest 2.5 mg for moderate pain and 5 mg for severe pain fentanyl o fentanyl 50 mcg IV once o fentanyl 25 to 50 mcg IV every 5 minutes PRN for pain (maximum 200 mcg total) o fentanyl mcg IV Suggest 25 mcg for moderate pain and 50 mcg for severe pain Consults oconsult Gastroenterology oconsult Hospitalist oconsult Internal Medicine oconsult General Surgery oconsult Page 6 of 6