Eating Disorder Clinical Practice Guideline Algorithm

Transcription

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2 Eating Disrder Clinical Practice Guideline Algrithm Identificatin Red Flags: Dramatic wt lss, underweight (% f pre-existing wt), fd/fluid refusal, dizziness, syncpe, chest pain/sob, cnstipatin, amenrrhea, hx f bingeing/purging, parental cncerns; feeding failure even thugh the patient is currently receiving services; uncntrlled purge cycle Histry: timing f wt lss, recent/typical fd/fluid intake, wt lss meds (PO/PR) bingeing, purging, menses, mental health issues, SI/HI, water lading, ver-exercising Vital Signs Resting HR & Orthstatics If HR <50: cardiac mnitr & EKG Orthstatic BP: If BP drps >20 mmhg rehydratin is required (see belw fr reference) Temperature: If temp < 36 C re-warming Grwth Parameters (Weight, Height, BMI) (a) Previus wt: kg (b) Current dry wt (gwn, n shes): kg Wt lss (a-b): kg Percentile: % Current height: cm Percentile: % BMI: Percentile: % Physical Exam Hydratin status Muscular weakness Mental Status (slwing/cnfusin) Skin Ulceratin (back/spine) Bruising Muscle Wasting Lanug Self harm scars

3 Wrk Up: * CMP, Mg, Phs, ica UA +/- UA, βhcg, UDS PTT, PT/INR (hemetemesis) CBC, ESR Amylase (purging) EKG: HR. QT (calc) ** TSH/Free T4 Accuchecks q30mins if eating in ED VS redne q1hr N Red Flags Stable HPI Stable Labs/Wrk Up Family is reliable fr f/u N scial cncerns Admissin is nt indicated Cntact Adlescent Medicine Team prir t If n answer, leave a message with pt s name, DOB, phne #, and referring Dr/facility AND call the Access center & cnsider transfer Send EPIC t Dr. Marianne Dustan Brady & Dr. Victria Crnelius with patient s chart attached cncerning this ED visit Discharge hme/transfer with a discharge set f VS & fllw up with PCP fr weight re-check After the ED visit, have parents call the fllwing: Medicaid & Insurance: McCallum Place Private Insurance: St. Luis Behaviral Medicine Institute (Chesterfield, MO) Supplemental Infrmatin fr parents: neda.rg Please see belw fr further instructins Abnrmal r cncerning labs Scial Cncerns Anrexia Nervsa <75% ideal bdy weight r nging weight lss despite intensive management Refusal t eat Bdy fat <10% Heart Rate <50 beats per minute daytime r <45 beats per minute nighttime SBP <90 Orthstatic changes in pulse (>20 beats per minute) r bld pressure (>10 mmhg) Temperature <96 F Arrhythmia Bulimia Nervsa Syncpe Serum ptassium cncentratin <3.2 mml/l Serum chlride cncentratin <88 mml/l Esphageal tears Cardiac arrhythmias including prlnged QTc Hypthermia Suicide risk Intractable vmiting Hematemesis Failure t respnd t utpatient treatment ACUTE dehydratin (ptinal) IV: NS 10 ml/kg ver 1-2 hr fr 3-5% (mild) dehydratin PO: water/juice 250ml q4hr Nte: mnitr HR & BP during hydratin fr stress induced tachycardia/hf

4 Crrect Electrlytes: K < 3.5: add 20-40mml KCl/L, recheck in 4hrs Na abnrmalities: IV NS hydratin, recheck in 4hrs Glucse <80: 200 ml PO juice, recheck in 30mins; IV glucse shuld be avided Phs <0.8: 500mg PO BID Phs <0.5: IV phsphate at mml/kg ver 6hrs; check levels 1hr pst-infusin, then 6hrs after that Mg <0.7: 500mg PO BID, max dse 2g Mg <0.5: IV Mg Sulfate 25-50mg/kg/dse q6hr x3dses, max rate 125mg/kg/hr with max dse 2g ADMIT/TRANSFER t the Adlescent Inpatient Team (range/purple team) This algrithm is designed t treat the majrity f children & yuth presenting t the ED with cmplaints cncerning with an Eating Disrder (ED). Phne Cnsultatin Only f Adlescent Patient: Access Center RN will Recrd Demgraphic Infrmatin & Physician Call Place Text Page t Cnsultatin Physician On-Call (AMION) If it is n Mnday Friday between the hurs f 8 AM 4:30 PM Access Center will ask referring MD t stay n the line AMION t page the fllwing staff: Dr. Marianne Dustan Brady Dr. Victria Crnelius After Hurs (NOT M-F between 8AM 4:30PM) Access Center will hang up phne They will cnsult the ED attending Cnsult Physician On-Call will call back Access Center within 10 minutes Access Center will set up Recrded 3-way Phne Call (Referring Physician, Cnsulting Physician & Access Center RN) If patient is instructed t fllw-up with clinic please give them the clinic number t call the next business day AND inbx Tara, Marianne, Victria & Theresa Frsythe s they can fllw up THE CLINIC IS CLOSED ON FRIDAY, SATURDAY, AND SUNDAY ANY EMERGENCY NEEDS TO COME TO OUR ED FOR TREATMENT Please have family call the ffice t arrange fr this appintment. Theresa Frsythe is the POC. *Electrlyte abnrmalities indicative fr eating disrders (ED): Glucse: (pr nutritin), (insulin missin) Sdium: (water lading r laxatives) Ptassium: (vmiting, laxatives, diuretics, refeeding) Chlride: (vmiting), (laxatives) Bld bicarbnate: (vmiting), (laxatives) Bld urea nitrgen: (dehydratin) Creatinine: (dehydratin, renal dysfunctin), (pr muscle mass) Calcium: slightly (pr nutritin at the expense f bne) Phsphate: (pr nutritin r refeeding) Magnesium: (pr nutritin, laxatives, refeeding)

5 Ttal prtein/albumin: (in early malnutritin at the expense f muscle mass), (in later malnutritin) Ttal bilirubin: (liver dysfunctin), (pr RBC mass) Aspartate amintransaminase (AST), alanine amintransaminase (AST): (liver dysfunctin) Amylase: (vmiting, pancreatitis) **Significant EKG findings: Bradycardia r ther arrhythmias, lw-vltage changes, prlnged QTc interval, T-wave inversins, and ccasinal ST-segment depressin. References: AED 2011 Eating Disrders: Critical Pints fr Early Recgnitin and Medical Risk Management in the Care f Individuals with Eating Disrders. N.p.: n.p., n.d. FEAST Educatin Resurces. Academy fr Eating Disrders' Medical Care Standards Task Frce. Web. 8 Oct < BC s Prvincial Cmmunity Hspital Prtcl (A): Recmmended Care f the Patient with an Eating Disrder in the Emergency Rm. N.d. Raw data. Prvincial Health Services Authrity, Prvidence. Cardinal Glennn Inpatient Guidelines t Eating Disrders Revised Aug Eating Disrders in the Emergency Department: Critical Pints fr the Recgnitin & Medical Management f Individuals with Eating Disrders in the Acute Care Setting. N.p.: AED Academy fr Eating Disrders, Print.