CENTRAL IOWA HEALTHCARE

Marshalltown, IA

EMERGENCY DEPARTMENT POLICY & PROCEDURES

Policy Number P-17

Subject: Triage Protocol

Purpose: To provide a pathway of timely, coordinated care for patients with urgent/emergent symptoms, determined

through assessment by an Registered Nurse (RN) that correspond to a specific triage protocol delegated by a

medical provider to reduce delays in medical treatment and care.

Policy: The Emergency Department (ED) RN will initiate the triage protocols if the patient assessment findings

warrant the intervention within their scope of competency and licensure. Protocols are complaint specific and

were developed to be within the critical thinking skill set of a bedside emergency room RN.

Procedures: Patient presents to the ED with specific symptoms that align with the current ED triage protocols, the RN

assessment confirmation of symptom(s) or condition that warrants initiation of protocols, then RN initiates

corresponding protocol(s) and consults with ED provider if additional clarification as needed.

Additional information:

The following triage protocols are applicable to all adult/pediatric patients experiencing the following

symptom(s) and/or condition(s):

Abdominal pain

Behavioral Health

Chest pain Adult

Diarrhea

Dyspnea

Pediatric Asthma

Dysuria

Eye problems

Fever

Flank pain

Flu-like symptoms

GI Bleeding

Laceration

Medical Imaging

Musculoskeletal pain

Nausea & vomiting

Seizure

Sepsis

Shortness of breath

Sore Throat

Stroke-like symptoms/Altered Mental Status

Syncope/Near Syncope (Fainting)

Vaginal bleeding

Nebulizer Treatment

Pediatric Fever

Allergic Reaction

Diabetic Emergency

Fever Adult

Neutropenic Fever

Pneumonia

Trauma-Minor

Trauma-Major

Pediatric-Simple Fever

Originated by: Emergency Department

Effective date: 6/15

Authorized by: ________________________________________________________

ER Medical Staff Director Date

________________________________________________________

Administration Date

Revision date: 10/15

Review date:

Appendix: Appendix A: Emergency Department Triage Protocols

Appendix B: Asthma Respiratory Severity Score

Appendix C: Oral Rehydration Therapy Guidelines

Appendix A:

Abdominal Pain

Nursing Saline Lock IV

DIET NPO (except medications) NPO (including medications)

Laboratory CBC w/Diff UA

CMP

Epigastric or RUQ Pain and age > 12 Add:

Lipase Serum

With Jaundice and/or on Warfarin Add:

PT(includes INR)

If Female of Menstruating Age and No Hysterectomy Add:

HCG Quant, Serum

Possible Cardiac Component or Upper Abdominal Pain > 40 years old, Add:

Troponin I Assay STAT EKG

MEDICATIONS (for patients > 12 years of age)

Zofran 4mg IVP x 1 PRN nausea

Or Zofran 4 mg ODT x 1 PRN nausea

GI cocktail PO x1 PRN upper abd pain

Behavioral Health

LABORATORY CBC CMP UDS ETOH TSH Acetaminophen Level Salicylates Level Urinalysis

SOCIAL WORK Consult Social Services

ABG’s

LABORATORY ABGs

Arterial Puncture

Chest Pain Adult

NURSING Suspect Cardiac Origin: Saline Lock IV (Antecubital)

Cardiac Monitoring Oximeter Continuous Oxygen- 2L /min Nasal Cannula titrate to keep O2 Sat > 92% Nurse Communication: Obtain old records including any EKG’s

DIET NPO (except medications) NPO (including medications)

LABORATORY CBC w/Diff

CMP Troponin I Assay

If on Warfarin Add: PT(includes INR) DIAGNOSTIC TESTING EKG (within 10 minutes of arrival) (To EDP STAT after completion) MEDICAL IMAGING Chest Single View Adult Portable

MEDICATIONS Aspirin initial 324 mg. PO chew tab x1 NGT 0.4 mg SL x3 PRN chest pain (Notify EDP if CP not relieved with 3 doses) (HOLD if SPB <90) Morphine 2mg IVP PRN chest pain up to 10 mg

Diarrhea

Nursing Saline Lock IV

LABORATORY Elderly Patients with Orthostatic Changes, or Any Patient with Suspected Volume Deficit:

CBC w/Diff CMP Nurse Communication: Collect & save stool specimen if possible UA Urine Culture (UR Culture Urine) if indicated

Nebulizer Treatments

MEDICATIONS Albuterol 1UD x 1 Atrovent 1UD x 1 Duoneb 1UD x 1 Pulmicort 0.25mg x 1 or 0.5mg x 1 Racemic epi 1UD x 1 Xopenex 0.31mg x 1 0.63mg x 1 1.25mg x 1

Nursing Nebulizer Treatment

1UD = 1 Unit Dose

Dyspnea

NURSING RNs may use their clinical judgment to initiate an SVN (small volume nebulizer) based on signs and symptoms including:

-Dyspnea and/or wheezing - Oxygen saturation <90% -Oximeter Continuous -Oxygen-2L/min NC, titrate to keep O2 Sat >90% (or Pediaflow for infants, titrate to > 92% SPO2)

For patients ages 1 year- 17 years old, RNs may initiate the ED Pediatric Asthma protocol based on an Asthma Respiratory Severity Score (RSS) as applicable

Call / request Respiratory to respond

RT Suction- age appropriate suction bulb or BBG nasal aspirator (Reserve deep suction for airway obstruction causing significant respiratory compromise)

RT SVN- Albuterol 2.5 mg SVN, Soln, 1 x ONLY Shortness of Breath or wheezing

RT Peak Flow Measurement 2 times- Perform Peak Expiratory Flow Rate (PEFR) before and after treatment if able (Exception infants and small children)

PEDIATRIC PATIENTS ONLY:

Mild: Barky Cough

MEDICATION

Dexamethasone (Decadron) 0.6mg/kg po, not to exceed 10 mg, 1 x only

Moderate/Severe: Barky Cough with active stridor, retractions at rest, retractions with severe respiratory distress, hypoxia, or cyanosis

If child is under 6 months of age:

RT SVN-Racemic epinephrine 0.3ml of 2.25% solution diluted in 3mL NS SVN, 1x ONLY

Pulmicort 0.25 neb x1 If child is 6 months of age or older:

RT SVN-Racemic epinephrine 0.5mL of 2.25% solution diluted in 3 mL NS SVN, 1x ONLY

Pulmicort 0.25 neb x1 If child is no longer moderate/severe:

Medication Dexamethasone (Decadron) 0.6mg/kg po, not to exceed 10 mg, 1 x ONLY Dexamethasone (Decadron) 0.6mg/kg IM, not to exceed 10 mg, 1 x ONLY. For use only if patient vomits oral dose.

Document patient assessment and notify provider as soon as possible after treatment has begun

Repeated SVNs are given only after the provider has been consulted or per ED Pediatric Asthma protocol

Pediatric Respiratory Distress

FIRST HOUR OF TREATMENT IN ED

Patients with a respiratory severity score 1-5: MEDICATION

RT-Duoneb (Albuterol 2.5 mg/0.5 ml and ipratropium 500 mcg in 3 ml solution)

Consult with provider prior to administering: Prednisolone 1 mg/kg PO once

Consult with provider prior to administering: Repeat Albuterol 2.5 mg/0.5 ml nebulized

Patients with a respiratory severity score 6-12: MEDICATION

RT-Duoneb treatment (Albuterol 2.5 mg/0.5 ml and ipratropium 500 mcg in 3 ml solution) then consult provider for further treatment

Titrate oxygen to keep SPO2 > 92%

Consult with provider prior to administering: Prednisolone 1 mg/kg PO once SECOND HOUR OF TREATMENT IN ED Patients with a respiratory severity score 1-4:

NURSING

Prepare for discharge

If a patient just received continuous Albuterol they should be observed for a minimum of 1 hour and rescored Patients with a respiratory severity score 5-8:

NURSING Observe for 1 hour and rescore after medication administered and report to ED Provider

MEDICATION

RT -Albuterol MDI 8 puffs

Patients with a respiratory severity score 9-12:

MEDICATION

RT-Duoneb treatment (Albuterol 2.5 mg/0.5 ml and ipratropium 500 mcg in 3 ml solution) then consult provider for further treatment

Titrate oxygen to keep SPO2 > 92%

Consider Magnesium sulfate IV 50 mg/kg (max dose 2 grams) x2 for patients not responsive to the 1st

hour of treatment

Dysuria

LABORATORY UA

Urine Culture (UR Culture Urine) if indicated)

If Female of Menstruating Age and No Hysterectomy Add:

HCG Quant, Serum Eye Problems

MEDICATIONS FOR SEVERE PAIN DUE TO POSSIBLE CORNEAL ABRASION OR FOREIGN BODY

CONSIDERATION: Do NOT use topical anesthetic (tetracaine or proparacaine) if there is a possible globe perforation.

tetracaine ophthalmic 3 drops, 1x ONLY

proparacaine ophthalmic 3 drops, 1 x ONLY NURSING

Visual Acuity Evaluation CHEMICAL SPLASH TO THE EYE(s) Check pH, but do not delay irrigation CONSIDERATION: Do NOT use topical anesthetic (tetracaine or proparacaine) if there is a possible globe perforation, if not contraindicated:

tetracaine ophthalmic 3 drops, 1x ONLY

proparacaine ophthalmic 3 drops, 1x ONLY

S-Sol Irrigation Sodium Chloride 1L (S-Solution Irrign NaCl 0.9 1L), use ocular irrigation set NURSING

Visual Acuity Evaluation

Pediatric Fever

Nursing Saline Lock IV

LABORATORY

Toxic appearance: CBC w/Diff

CMP Lactic Acid

Blood Culturex1

UA Nurse Communication: urinalysis – clean catch or catheter

MEDICATION

Consider Acetaminophen when: 1. the child's temperature is 38.0 C or higher 2. The child was under dosed according to weight guidelines 3. Or the last dose was vomited regardless of the time it was given. Consider Ibuprofen when Acetaminophen was given within the last 4 hours and if the child’s temperature to 38.0 C or greater.

14 years and younger:

Acetaminophen 15 mg/kg PO or rectal x1 For children age 6 months to 14 years:

Ibuprofen 10 mg/kg PO x1

If Neonatal Fever:

IV Saline Lock

Straight Catheter Insert NEO UA catheterize

Urine Culture - catheterize Blood Culture x 1

Draw red top to hold

Lidocaine 4% cream (LMX /Ela-max)- apply up to 5 gm to lumbar spine area

PEDIATRIC – SIMPLE FEVER LABS: RSV Influenza Rapid Strep MEDICATIONS: Motrin: 10mg/kg all children > 6 months if no med within 6 hours. Tylenol: 15 mg/kg all children if no med within 4 hours.

Flank Pain

NURSING Saline Lock IV

LABORATORY

CBC w/Diff

Comprehensive Metabolic Panel

UA

Urine Culture (UR Culture Urine) if indicated) If Female of Menstruating Age and No Hysterectomy Add:

HCG Qual, Serum

Flu-like Symptoms

LABORATORY Strep Influenza A/B

GI Bleeding NURSING

Saline Lock IV

LABORATORY

CBC w/Diff

CMP

PT/PTT (include INR)

If Hemodynamically Unstable, add:

Type and Screen

If Chest Pain, see Chest Pain

Musculoskeletal Pain

Nurse Communication: Provider comfort measures i.e. Ice, pillow, elevation and consult MD for pain medication

MEDICATION

For patients under 18 years old presenting with pain associated with minor closed head injury and/or musculoskeletal injury Consider Ibuprofen for pain when child is over 6-months-of-age: 1. If the child was not already given ibuprofen Consider acetaminophen for pain if: 1. Ibuprofen was given within the last 6 hours, 2. the child is allergic to ibuprofen, 3. The child is under 6-months-of age

Ibuprofen 10mg/kg PO, not to exceed 800mg, 1 x ONLY Acetaminophen 15mg/kg PO, not to exceed 1000mg, 1 x ONLY

Allergic Reaction

LABORATORY CBC with Diff BMP

Nursing Cardiac Monitor Pulse Oximeter Oxygen Nebulizer Treatment

Medications IV Saline Lock 0.3ml/1:1000 Epinephrine IM x 1 Xopenex Benadryl PO 50mg x 1 0.31mg x 1 nebulizer Benadryl IM 50mg x 1 0.63mg x 1 nebulizer Benadryl IV 25mg x 1 1.25mg x 1 nebulizer Pepcid IV 20 mg IV x 1 0.3ml/1:1000 Epinephrine SQ x 1

Diabetic Emergency

LABORATORY CBC with Diff CMP

Nursing Accucheck – Glucose Diet Medications IV Saline Lock IV NS TKO D50 IV 1 AMP

Fever Adult

LABORATORY CBC with Diff CMP UA Urine Culture Blood Culture Flu Strep

Medical Imaging X-Ray Medications Tylenol 650mg or 1000mg PO/PR

Ibuprofen 400mg PO IV NS TKO

Neutropenic Fever

LABORATORY CBC with Diff CMP Lactate Blood Culture Urine Culture UA

Medical Imaging X-ray Nursing IV Saline Lock Tylenol 1000mg PO/PR Motrin 400mg PO

Pneumonia

LABORATORY CBC with Diff CMP UA Urine Culture Blood Culture CRP – quant Lactate

Medical Imaging X-Ray Nursing IV Saline Lock

IV NS TKO Tylenol 650mg or 1000mg PO/PR Ibuprofen 400mg PO

Trauma-Minor

Medical Imaging: X-Ray Nursing ICU

Elevate Suture Set-Up

Medication Adacel IM 0.5ml IM x 1

Trauma-Major LABORATORY CBC with Diff

CMP PT/PTT ETOH Pregnancy Qualitative Pregnancy Quantitative Urine Drug Screen UA Blood Bank Lactate Lipase

Medical Imaging X-ray Ultrasound CT Scan

Nursing Cardiac Monitor Pulse Oximeter NPO Oxygen C-Collar NG Tube Foley Catheter Chest Tube Set Up

Medication: IV NS with Bolus IV #2 NS IV RL Zofran IV 4mg x 1, may repeat x 1 for total of 8mg Fentanyl IV Adacel 0.5ml IM x 1

Nausea and Vomiting

Nursing Saline Lock IV For pediatric patients greater than 6 months old, may start Oral Rehydration Therapy (ORT) per protocol as applicable

LABORATORY UA

CMP CBC w/Diff

If Female of Menstruating Age and No Hysterectomy Add: HCG Quant, Serum

MEDICATIONS 2 mg for weight from 8 to 16 kg 4 mg for weight >16 kg

Ondansetron (Zofran®) mg PO ODT (Disintegrating) Tablet or liquid now

If Abdominal pain follow Abdominal pain care set

Seizure

NURSING Saline Lock IV Nurse Communication, place seizure pads around patient. Telemetry

LABORATORY

Glucose Point-of-Care (Finger-Stick Glucose)

With Prior Seizure History and On One Of These Medications Add: Carbamazepine (Tegretol) Level Dilantin Level

Valproic Acid (Depakane) Level Phenobarbitol Level

If Fever or Obtunded Add:

UA

Urine Culture (UR Culture Urine) if indicated CBC w/Diff CMP

If Female of Menstruating Age and No Hysterectomy Add:

HCG Quant, Serum

Sepsis Patients who present with at least 2 of the following: □ Temperature < 36 or > 38 ⁰ C □ HR > 90 □ Respirations > 20

AND SBP < 90 AND at least one of the following risk factors: □ Diabetic □ Indwelling Catheters □ Immunosuppressed □ Transfer for SNF □ Decreased LOC □ Age > 50

NURSING Saline Lock IV x2 Cardiac Monitoring

Oximeter Continuous Oxygen- 2L /min Nasal Cannula titrate to keep O2 Sat > 90%

LABORATORY CBC w/Diff

CMP

Lactic Acid Blood Culturex2 UA Urine Culture

MEDICATIONS Normal Saline 2 liter bolus x1 Acetaminophen 15mg/kg PO, not to exceed 1000mg, 1 x ONLY Ibuprofen 10mg/kg PO, not to exceed 800mg, 1 x ONLY MEDICAL IMAGING Portable Chest X-Ray

Shortness of Breath

Does Not Apply to Uncomplicated Asthma in a Young Patient, see Dyspnea

NURSING Saline Lock IV

Oximeter Continuous Oxygen- 2L /min Nasal Cannula titrate to keep O2 Sat > 90%

LABORATORY CBC w/Diff

CMP

If Cardiac Origin Add: BNP Troponin I Assay

DIAGNOSTIC TESTING EKG

MEDICAL IMAGING Chest Single View Adult Portable

Chest PA + Lat

Sore Throat

LABORATORY Strep

Stroke-like Symptoms/Altered Mental Status (Facial droop, arm drift, abnormal speech, etc.) NURSING Saline Lock IV

Oximeter Continuous Continuous Cardiac Monitoring Oxygen- 2L /min Nasal Cannula titrate to keep O2 Sat > 90% AccuCheck

DIET NPO (except medications)

NPO (including medications)

Laboratory CBC w/Diff UA

CMP PT/PTT

Glucose Point-of-Care (Finger-Stick Glucose)

DIAGNOSTIC TESTING EKG Head CT non-contrast (To be determined after EDP evaluates)

Syncope/Near Syncope (Fainting)

NURSING Notify Physician if Hemodynamically unstable Continuous cardiac monitoring Orthostatic vitals Saline Lock IV AccuCheck

LABORATORY Draw Extra Tubes for Possible Cardiac Enzymes, PT, INR, PTT, Toxicology Studies, Type and Screen

CBC w/Diff CMP UA

If Female of Menstruating Age and No Hysterectomy Add:

HCG Quant, Serum Apply Blood Band ID to Specimens

DIAGNOSTIC TESTING EKG

Vaginal Bleeding

LABORATORY UA

CBC w/Diff

If Female of Menstruating Age and No Hysterectomy Add:

HCG Qualitative, Serum

If Patient Reports a Positive Pregnancy Test or has a Positive Pregnancy Test Add:

Type and Rh HCG Quant, Serum

If on Warfarin Add: PT(includes INR)

Laceration

MEDICATION If last tetanus immunization greater than 5 years or unknown, and no history of adverse reaction to tetanus (IF CHILD IS UNDER 10 YEARS OF AGE, CONTACT PROVIDER)

diphtheria/pertussis, adacel/tetanus adult (diphtheria/pertussis/tetanus) 0.5mL IM 1X ONLY

For topical anesthetic use at laceration site on face or scalp (DO NOT USE for fingers, toes, nose, or ears)

LET topical anesthetic solution- apply up to 3 mL to an open wound for 20-30 minutes

For patients under 18 years old presenting with pain associated with minor closed head injury and/or laceration Consider Acetaminophen for pain: If the child was not already given acetaminophen Consider Ibuprofen for pain when child is over 6-months-of-age AND Acetaminophen was given within the last 4 hours or the child is allergic to acetaminophen

Acetaminophen 15mg/kg PO, not to exceed 1000mg, 1 x ONLY Ibuprofen 10mg/kg PO, not to exceed 800mg, 1 x ONLY

Medical Imaging

PRIOR TO ORDERING 1. Nurse may order two sites (all views) for x-rays. Consult with physician if more than two sites (all views) needs to be

ordered, unless special instructions are noted in “WHAT TO ORDER” 2. Question patient for possible pregnancy

3. Examine injured area and initiate ice, immobilization and elevation 4. Request analgesia ASAP as needed 5. Always palpate joints above and below injury to assess for other injuries

6. Always disrobe and move from wheelchair to stretcher for lower extremity or back injuries.

INDICATIONS: 1. Injury confined to extremities 2. Presence of deformity, instability, crepitus, point tenderness, ecchymosis, swelling or pain 3. Patient request which meets above criteria 4. History significant for probable fracture

PROVIDER CONSULTATION NEEDED: 1. Any time multiple sites may need to be taken 2. Any doubts the nurse has on which films to order, i.e. unable to localize injury

3. All patients possibly pregnant 4. Any associated injury to head, neck or trunk 5. Any evidence of neurovascular compromise

WHAT TO ORDER "Heard a pop", inversion or eversion ankle injury; swelling at malleoli. Palpate fifth metatarsal and if pain present, order a foot x-ray also. Ankle film does not visualize the metatarsals well.

Ankle 3 Or More Views Lt Ankle 3 Or More Views Rt

Post traumatic pain if associated with decrease or loss of supination, pronation, flexion or extension. ** In a child of 5 years or less with unexplained loss of arm function and no apparent soft tissue swelling, a radial head subluxation must be considered and x-rays should not be obtained prior to physician evaluation.

Elbow 3 Or More Views Lt Elbow 3 Or More Views Rt

If swelling or pain on top of foot.

Foot 3 Or More Views Lt Foot 3 Or More Views Rt

Clear hand injury distal to wrist

Hand 3 Or More views Lt Hand 3 Or More Views Rt

Order special calcaneal films if fracture suspected

Calcaneus [Heel] Lt Calcaneus [Heel] Rt

1. Inability to stand or walk with localized knee pain 2. Post traumatic joint effusion 3. A fall or blow to the knee/patellar area with subsequent inability to flex or extend the knee fully. If pain over patellar

area, add order for sunrise (patellar) view

Knee 23 View Lt Knee 23 View Rt

Tenderness above the shoulder or on top of the shoulder; may or may not have swelling/deformity.

Shoulder 2 Or More Views Lt Shoulder 2 Or More Views Rt

1. Fall on an outstretched hand with swelling and tenderness to the wrist

2. If snuffbox tenderness, a comment of "navicular view" in the order comments.

Wrist 3 Or More Views Lt Wrist 3 Or More Views Rt

Post traumatic pain in hip area if associated with rotated and shortened leg

Hip 2 Or More Views Lt Hip 2 Or More Views Rt Pelvis 1 or more views

Post traumatic pain in thigh area with swelling or pain to thigh area

Femur 2 Or More Views Lt Femur 2 Or More Views Rt

Pain, Swelling, or deformity to affected joint: Tibia/fibula 2 views Lt Tibia/fibula 2 views Rt

Formatted: Indent: Left: 0.31"

Formatted: Indent: Left: 0.56"

Appendix B

Central Iowa Healthcare Clinical Asthma Score

Score range: 0 – 12

< 5 = mild; > 9 = severe

Variable Respiratory Score (Circle One)

0 point 1 point 2 points 3 points

Respiratory rate

(breaths/min)

COUNT RESPIRATORY RATE FOR ONE FULL MINUTE

while patient is awake

< 2 months < 60 61-69 > 70

2-12 mos < 50 51-59 > 60

1-2 yr < 40 41-44 > 45

2-3 yr < 34 35-39 > 40

4-5 yr < 30 31-35 > 36

6-12 yr < 26 27-30 > 31

> 12 yr < 23 24-27 > 28

Retractions None Subcostal or

intercostal

2 of the following:

subcostal,

intercostal,

substernal, OR

nasal flaring

(infants)

3 of the following:

subcostal,

intercostal,

substernal,

suprasternal,

supraclavicular OR

nasal flaring or

head bobbing

(infants)

Dyspnea

0-2 years Normal feeding,

vocalizations, and

activity

1of the following:

difficulty feeding;

decreased

vocalization; OR

agitated

2 of the following:

difficulty feeding;

decreased

vocalization; OR

agitated

Stops feeding, no

vocalizations, OR

drowsy or

confused

2-4 years Normal feeding,

vocalizations, and

play

1 of the following:

decreased appetite,

increased coughing

after play,

hyperactivity

2 of the following:

decreased appetite,

increased coughing

after play,

hyperactivity

Stops eating or

drinking, stops

playing, OR

drowsy or

confused

> 5 years Counts to > 10 in

one breath

Counts to 7-9 one

breath

Counts to 4-6 in

one breath

Counts to < 3 in

one breath

Auscultation

(as it relates to

wheezing)

Normal breathing;

no wheezing

present

End-expiratory

wheeze only

Expiratory wheeze

only (greater than

end-expiratory

wheeze)

Inspiratory and

expiratory wheeze

OR diminished

breath sounds OR

both

Appendix C

Dehydration/Oral Rehydration Clinical Practice Guidelines This guideline has been developed to ensure proper rehydration in patients 1 to 60 months of age with acute gastroenteritis (diarrheal illness of rapid onset with or without nausea, vomiting, fever, abdominal pain) and with no other diagnosed disorders. The guideline is not to be used in patients with diarrhea for over 10 days, diarrhea associated failure to thrive, or vomiting without diarrhea. The recommendation to withhold antibiotics should be modified if a protozoal illness is suspected or if dysenteric signs and symptoms (fever, bloody stool, pus in stool) are present. Contra-indications to oral rehydration are outlined on page 2. Please direct questions to Dr. Lance VanGundy at 641-754-5040.

EVALUATION OF DEHYDRATION The most accurate way to estimate dehydration is to compare a recent weight (when the patient was well) and the current weight. Clinical parameters to assess hydration status are outlined below. The appropriate method of rehydration depends on the percent dehydration.

Mild (3-5%) Moderate (6-9%) Severe (>10%) General Alert Restless, Irritable Lethargic/unconscious Blood Pressure Normal Normal Normal, decreased Quality of Pulse Normal Normal, slightly decreased Moderately decreased Heart Rate Normal Increased Increased Skin Turgor Normal Decreased Decreased Fontanelle Normal Sunken Sunken Mucus Membranes Slightly dry Dry Dry Eyes Normal Sunken Deeply sunken Extremities Warm, normal cap refill Delayed cap refill Cool, mottled Urine Output Slightly decreased < 1 ml/kg/hr << 1 ml/kg/hr Thirst Slightly Increased Moderately increased Increased/Decreased

ORAL REYDRATION THERAPY (ORT) is appropriate for patients with mild and moderate dehydration. Compared to IV rehydration, ORT is safer, less costly, and able to be administered in various clinical settings.

Oral rehydration solutions (ORS) should contain 45-90 mmol/L of sodium and 74-140 mmol/L of glucose. Acceptable, commercially available ORS include: Naturalyte, Pedialyte, Infalyte, Rehydralyte, WHO Oral Rehydration Salts, and Pediatric Electrolytes. Cereal-based ORS is also available and has been shown to decrease diarrhea by 20-30% compared to glucose-containing ORS. Rehydralyte is the most appropriate ORS that is easily available.

Fluid replacement should be accomplished over 3-4 hours; additionally, 10 ml/kg for each episode of vomiting or watery stool will prevent further dehydration. For patients who are vomiting, 5 ml of ORS every 1-2 minutes should be attempted. For patients who refuse to take ORS orally or who continue to vomit, continuous nasogatric tube (NGT) rehydration should be considered.

Less than 3% dehydration (determined by weight or estimation): Encourage PO liquids and solids. Milk products and breastfeeding should be continued. There is little indication for ORS. Close monitoring for worsening dehydration is recommended and ORS to replace ongoing losses may be recommended (10ml/kg for each episode of vomiting or watery diarrhea).

MILD = 3-5% dehydration (determined by weight or estimation): Use ORS (orally or by NGT) to replace 50 ml/kg (or the exact losses if known by weight change) plus ongoing losses (10 ml/kg for each episode of vomiting or watery diarrhea) over 4 hours. Reevaluate every 2 hours. Begin age-appropriate diet after rehydration is accomplished. Continue to replace ongoing losses with ORS (10ml/kg for each episode of vomiting or watery diarrhea).

MODERATE = 6-9% dehydration (determined by weight or estimation): Use ORS (orally or by NGT) to replace 100 ml/kg (or the exact losses if known by weight change) plus ongoing losses (10 ml/kg for each episode of vomiting or watery diarrhea) over 4 hours. Reevaluate every hour. Begin age-appropriate diet after rehydration is accomplished. Continue to replace ongoing losses with ORS (10ml/kg for each episode of vomiting or watery diarrhea).

SEVERE = Over 9% dehydration (determined by weight or estimation): Arrange hospital admission, initiate IV fluids (20ml/kg lactated Ringer’s or normal saline), order appropriate laboratory studies, and begin ORT when patient is stable and improved. Age-appropriate feedings may be resumed after rehydration is accomplished.

EARLY REFEEDING is recommended. Patients who are not dehydrated may continue their typical age- appropriate diet. Dehydrated patients may resume their typical age-appropriate diet after being rehydrated. Most patients tolerate lactose-containing milk/formula safely. If a patient has worsening diarrhea with the resumption of lactose-containing products, consider checking stool for pH and reducing substances and instituting a lactose-free diet for 2 weeks. Breastfeeding should be continued during acute diarrheal illnesses. Foods that are well tolerated include: rice, wheat, potatoes, bread, cereal, lean meat, fruit, yogurt, vegetables. Poorly tolerated foods include: fatty foods, food or drinks high in simple sugars (juice, soft drinks/soda).

TYPICAL COURSE: The usual course of a diarrheal illness includes one to two days of fever and vomiting, followed by three to four days of diarrhea. Even severely dehydrated children are willing to attempt PO intake on the second or third day of illness. Discharge criteria from an in-patient hospital stay should include rehydration accomplished, oral intake of fluids adequate to maintain hydration status and follow-up arranged. For patients rehydrated in the ED or out-patient setting, follow-up should include: a phone call by the primary care provider the following day for cases of mild dehydration or a phone call the same day and an office visit the following day for moderate dehydration.

HYPERNATREMIC DEHYDRATION is dehydration associated with serum sodium over 150 mEq/L. It is associated with a doughy feeling of the skin and mental status changes. Patients with hypernatremic dehydration can be safely rehydrated orally. However, if the patient requires IV rehydration, the sodium deficit should be replaced slowly (over 48 hours) to prevent CNS complications. Frequent serum sodium levels are indicated.

SERUM ELECTROLYTES are helpful in patients with: signs and symptoms of hypernatremic dehydration, severe dehydration, or a history/physical exam that is inconsistent with straightforward acute gastroenteritis. STOOL STUDIES may be considered based on the clinical situation; C. diff toxin, culture, WBC, O&P, Giardia antigen may be considered but are not recommended if a virus is the most obvious source. Rotavirus antigen testing is rarely required, except for epidemiology studies and cohorting purposes.

CONTRA-INDICATIONS TO ORAL REHYDRATION AND ADMISSION CRITERIA Over 9% dehydrated (determined by weight or estimation) Signs of shock Ileus or intestinal obstruction (proven or suspected) Comatose or unconscious Unable to tolerate ORT/NGT rehydration (persistent vomiting) Unclear diagnosis Significant psychosocial situation

ANTI-DIARRHEAL THERAPIES are not recommended. ANTI-EMETIC THERAPIES are not routinely recommended; however, studies have demonstrated short-term benefits with PO or IV ONDANSETRON.

ANTIBIOTICS are not typically recommended for acute gastroenteritis except for patients with a proven or highly suspicious diagnosis of a parasite/Giardia or patients with dysentery and the following: less than 6 months of age, systemic illness, proven or high suspicion of Shigella.

REFERENCES

1. American Academy of Pediatrics. Practice parameter: the management of acute gastroenteritis in young

children. Pediatrics 1996;97:424-35. 2. Burkhart DM. Management of acute gastroenteritis in children. American Family Physician 1999;60:2555-66. 3. Nager AL, Wang VJ. Comparison of nasogastric and intravenous methods of rehydration in pediatric patients with

acute dehydration. Pediatrics 2002;109:566-72. 4. Ramsook C, Sahagun-Carreon I, Kozinetz CA, Moro-Sutherland D. A randomized clinical trial comparing oral

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Algorithms are not intended to replace providers’ clinical judgment or to establish a single protocol. Some clinical problems may not be adequately addressed in this guideline. As always, clinicians are urged to document management strategies. Last revised March 2005 by The Barbara Bush Children’s Hospital at Maine Medical Center.