POLICY STATEMENT This order may only be activated under the specific circumstances set out in the section Indications and provided there are no contraindications present. The administering nurse must be accredited to administer the drug and record the administration in ink on the once only section of the medication chart. This order must be checked and signed by a medical officer within 24 hours, and preferably within 4 hours, of activation of the standing order. This standing order is only valid until the date noted by the Drug and Quality Use of Medicines Committee under the heading "Effective To:" at the end of this document. 1. NURSING ACCREDITATION REQUIREMENTS Accredited Registered Nurses employed within SESLHD Emergency Departments (ED) who are working in a extended practice nurse or Advanced Clinical Nurse (ACN) capacity must have at least a minimum of two (2) years emergency / critical care experience and must be able to work at a minimum of resuscitation level or above (i.e. triage / clinical initiatives nurse) and/or as approved by the ED Nurse Manager. 2. INDICATIONS Adults and paediatric patients (1 year of age and over) who present to SESLHD Emergency Department (ED) with mild to moderate asthma and: are able to tolerate inhaled medications have a known history of asthma present with audible wheeze OR wheeze on auscultation rated as mild to moderate as per asthma severity scale (section 5) 3. CONTRAINDICATIONS Less than 1 year of age Haemodynamically unstable (meets PACE / Between The Flag criteria 2 ) Hypersensitivity to salbutamol sulphate or other sympathomimetics 4. PRECAUTIONS 1 Cardiac disease Cardiac arrhythmias Hypokalaemia Diabetes mellitus. (monitor hypoglycaemic affect) Hyperthyroidism. Caution in thyrotoxicosis Use in pregnancy (Category A) Use in lactation Treatment with other sympathomimetic amines REV 1 February 2015 Page 1 of 5
5. ACTIONS/MONITORING REQUIRED Pre administration: Assessment of previous treatments utilised prior to arrival to the emergency department, and time that last salbutamol sulfate was given/taken Complete respiratory assessment - auscultate chest A full set of vitals (heart rate, blood pressure, respiration rate, and temperature) must be taken prior to administration. Obtain spirometry or peak-flow prior to bronchodilator administration Assess severity 5 : Assessed Severity Mild Moderate Severe Life-threatening Altered consciousness No No Agitated Agitated, Confused, Drowsy Accessory muscle use No Minimal Moderate Severe Oximetry in air >94% 90-94% <90% <90% Talks in Sentences Phrases Words Words Pulsus paradoxus Not present May be palpable Palpable Palpable Pulse rate Normal Mild-mod tachycardia Mod-marked tachycardia Marked tachycardia or bradycardia Central cyanosis No No Likely to be present Likely to be present Wheeze on Variable Moderate-loud Often quiet Often quiet auscultation Physical exhaustion No No Yes Yes If patient meets severe asthma criteria seek immediate medical review. Documentation: Document patient observations including the patient s pain score on the ED Standard Adult General Observation (SAGO) Chart and/or electronically within Firstnet. The administering nurse must record the administration in ink on the once-only section of the National Inpatient Medication Chart (NIMC) or Paediatric National Inpatient Medication Chart (PNIMC) as Emergency Department Standing Order (i.e. ED SO ) plus print and sign their name. Date, time, drug, dose, and route must be completed. The EDSO drug order must be countersigned by the medical officer that subsequently assesses and treats the patient within 4 hours. The administering nurse must record in the patient s progress notes the administration and effect of the medication. Drugs must be checked and ordered according to hospital policy and adhering to the Ministry of Health Policy Medication Handling in NSW Public Health Facilities PD2013_043. Post administration: Evaluate and document therapeutic response Complete a respiratory assessment auscultate chest and a complete a full set of vitals (heart rate, blood pressure, respiration rate and temperature) Re-assessment within 20 minutes of administration If severe asthma initiate salbutamol sulfate and immediately notify an ED senior medical officer Notify a medical officer if patient meets PACE / Between The Flag criteria 1 Monitor for side effects and consider anti-emetics if nausea/vomiting develops REV 1 February 2015 Page 2 of 5
6. PROTOCOL/ADMINISTRATION GUIDELINES: Caution: CHECK for allergies and/or contraindications Drug Dose Route Frequency Salbutamol sulfate in Mild / Moderate asthma severity 1 to 5 years or less than 20 kg: 6 puffs (600 microg) 6 years or 20 kg and over: 12 puffs (1,200 microg) Inhaled via spacer Once only Salbutamol sulfate in Severe asthma severity* 1 to 5 years or less than 20 kg: 6 puffs (600 microg), or 2.5 mg via nebuliser Inhaled via 6 years or 20 kg and over: 12 puffs (1,200 microg), or 5 mg via nebuliser spacer OR Nebulised Once only Seek senior MO review* Nebulisers: Administer nebuliser, or via wall oxygen at flow rate 6-8 L/min. Dilute to 2-3 ml with normal saline, nebulise until entire solution consumed. Spacers: Patients with poor inhaler technique will benefit from the consistent use of a spacer device with their metered aerosol. Use of a spacer will also decrease the amount of drug deposited in the mouth and back of the throat, and therefore reduce the incidence of local irritation in susceptible patients. *Note: The most senior clinician should assess a child with life-threatening or persistent severe asthma, discuss management with local specialists and transfer the child to a Children s Hospital (NETS 1300 36 2500) For further information on the management of Acute Asthma refer to Appendix 1: Algorithm Assessment & Initial Management of Acute Asthma 7. POTENTIAL ADVERSE EFFECTS/INTERACTIONS 1 : Most common: headache, inhalation site sensation, nervousness Uncommon: cough, tremor, dizziness, hyperkinesia, nausea and vomiting, tachycardia, palpitations, increased respiratory symptoms, pharyngitis, bronchospasm, chest pain, hyperglycaemia, cramps, hyperactivity, insomnia, hypokalaemia, hyperactivity in children Interactions: Beta-blocking drugs, other sympathomimetics, imipramine, chlordiazepoxide, chlorpromazine REV 1 February 2015 Page 3 of 5
8. REFERENCES: 1. MIMS Online. Salbutamol sulfate. 2014 [cited 25/8/14] Available from: https://www.mimsonline.com.au.acs.hcn.com.au/search/fullpi.aspx?modulename=product%20info &searchkeyword=salbutamol&previouspage=~/search/quicksearch.aspx&searchtype=&id=40090 002_2 2. SESLHD. Patient with Acute Condition for Escalation (PACE): Management of the Deteriorating Adult and Maternity Inpatient (SESLHD/PR283). 2013 [cited 2014 March]; Available from: http://www.seslhd.health.nsw.gov.au/policies_procedures_guidelines/clinical/governance/docume nts/seslhdpr283-pace-mgtofthedeterioratingadultmaternityinpatient.pdf. 3. Clinical Emergency Response System (CERS) for Paediatric Inpatients: Management of the Deteriorating Paediatric Inpatient. SESLHDPR/284. http://www.seslhd.health.nsw.gov.au/policies_procedures_guidelines/clinical/governance/docume nts/seslhdpr284-clinicalemergencyresponsesystemcers- MgtDeterioratingPaediatricInpatient.pdf 4. Ministry of Health Policy Medication Handling in NSW Public Health Facilities PD2013_043 http://www0.health.nsw.gov.au/policies/pd/2013/pdf/pd2013_043.pdf 5. Ministry of Health Policy PD2012_056 Infants and Children: Acute Management of Asthma Clinical Practice Guideline. http://www0.health.nsw.gov.au/policies/pd/2012/pdf/pd2012_056.pdf Authorised by: Name Designation Signature Date Endorsed by: Name Designation Signature Date Endorsed Effective To: REV 1 February 2015 Page 4 of 5
Appendix 1: Algorithm: Assessment and initial management of acute asthma 7 REV 1 February 2015 Page 5 of 5