Dostinex

Garret A. FitzGerald MD

• Chair, Department of Pharmacology
• Director, institute for Translational Medicine and Therapeutics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia

http://www.itmat.upenn.edu/faculty_fitzgerald.html

To avoid recall bias breast cancer ribbon tattoo 0.25 mg dostinex overnight delivery, this should be done as soon as possible after the evaluation period is completed breast cancer gene buy dostinex with american express. An active process menstruation hunger order dostinex 0.25mg with mastercard, such as distributing surveys during unit meetings menopause supplements dostinex 0.5mg with mastercard, may be more reliable than a pas sive process, where forms are left in the clinical area and flled out at random, and also pre vents staff from completing multiple evaluation forms for the same product. Depending on the number of staff involved and survey forms completed, this can be done either by hand or by use of a computerized database. It is useful to score each question in addition to the overall response, particularly if evaluating two or more devices. In addition, categorize individual comments so they provide a better picture of the clinical experience with the device. Consider calculating response rates by occupation and clinical area and analyzing data by these variables, if the volume of responses permits. This can help identify differences in opinion that may be infuenced by variations in clinical needs. Several factors can have a positive or negative infuence on the outcome of a product evaluation. These include: Staff experience with and preference for the conventional device; Attitudes toward involvement in the product evaluation process; Infuence of opinion leaders; Staff opinion of product evaluation team members and manufacturers representatives; Perceived need for devices with safety features; and Patient concerns. It is possible that one or more of these factors may be infuencing opinions if the response of certain groups of personnel to the product change is different from what was expected or differs from other groups in the organization. Meet with these groups to understand their issues; it might provide new insights for the evaluation team. Select and Implement the Preferred Product the evaluation team should make a product selection based on user feedback and other con siderations established by the selection team. Model the process for implementing the selected device after the pilot evaluation process, and coordinate training with product replacement. It may be necessary to implement a product change over several weeks, moving by unit within the hospital. The team should also consider a back-up plan in case the selected device is recalled or produc tion is unable to meet current demands. Questions to ask include: Should a less-preferred product be introduced as a replacement Furthermore, it is counter to the prevention plan to return to a conventional device once one with a safety feature has been introduced, and it may raise questions among staff. It is worth asking the representative that works with the hospital about this option. Perform Post-implementation Monitoring Once a new device is implemented, assess continued satisfaction with the product through fol low-up monitoring and respond to those issues not identifed or considered during the evaluation period. In addition, some facilities may wish to assess post-implementation compliance with use of the safety feature. Each product selection team will need to consider the most effective and effcient way to perform post-implementation monitoring. As part of the program planning process, care ful thought should be given to how and when training is provided to ensure that those who need training receive it, and that the training is relevant to those who are being trained. Healthcare Personnel as Adult Learners Adult learners are very different from child learners. One reason is, unlike children, adults enter the learning process after years of personal experience. Adults have existing knowledge, beliefs, and attitudes that infuence what they take from or contribute to a learning opportunity. Unfortunately, much of the education and training of healthcare personnel is more typical of tradi tional schooling and is provided in the context of meeting regulatory requirements. As such, there is often a resistance or lack of personal motivation to attend lectures or view videotapes or other self-directed teaching tools. This Workbook provides a reference for those who wish to read more about adult learning the ory and teaching methods (130). The remainder of this section discusses various opportunities and methods for training healthcare personnel in order to make it meaningful experience for the learner. However, there are many other opportunities, including staff training on procedures that involve use of sharps and the introduction of new devices. Decide exactly what information each Opportunities for Sharps Injury of these teaching opportunities will Prevention Training provide. Content for an Orientation or Annual Training on Sharps Injury Prevention As mentioned above, adults learn best when the information is relevant to their work. For that reason, it is useful to incorporate local information on sharps injuries and sharps injury prevention in the training. Information on the hierarchy of controls and how this concept is applied in the facility: Strategies to reduce or eliminate the use of needles. Administrative activities designed to decrease sharps injuries: Development of a sharps injury prevention team; Changes or improvements in exposure reporting procedures; and Safety culture initiatives. If the training is primarily lecture, methods to make the training more interesting might include: Presentation of case studies of exposures (protect the confdentiality of workers involved). At the end of the case presentation, the trainer might engage the audience in a discussion of how to prevent the injury. Teaching Tools Tools to enhance the learning process have evolved over the years, from the simple chalk board to overhead transparencies, paper fip charts, slides, flms, and more recently to video and au dio-tapes, teleconferences, computerized and non-computerized self-study programs, interac tive video, and other methods. Self-study educational materials enable healthcare personnel to receive training at their own convenience and pace; these are becoming increasingly important. Most healthcare organizations do not have the resources to develop sophisticated educational materials for sharps injury prevention. However, various professional organizations, device manu facturers, and federal agencies. As interest in this area grows, it is likely that an increasing number of resources will be available to facilities to use for training. We have provided a links to these sites because they have information that may be of interest to you. Estimate of the annual number of per cutaneous injuries among hospital-based healthcare workers in the United States, 1997 1998. Serial nosocomial trans mission of Plasmodium falciparum from patient to nurse to patient. Underreporting of blood and body fuid exposures in health care set tings: an alarming issue [Abstract]. In: Proceedings of the International Social Security Association Conference on Bloodborne Infections: Occupational Risks and Prevention. Evaluation of safety devices for preventing percutaneous injuries among health care workers during phlebotomy procedures Minneapolis-St. Occupational exposures to body fuids among medical students: a seven-year longitudinal study. Epidemiology and reporting of needle-stick in juries at a tertiary cancer center [Abstract P-S2-53]. In: Program and abstracts of the 4th International Conference on Nosocomial and Healthcare-Associated Infections; Atlanta, March 5-9, 2000:123. A survey of percutaneous/mucocu taneous injury reporting in a public teaching hospital. Safety-engineered device implementation: does it intro duce bias in percutaneous injury reporting Percutaneous injury, blood exposure, and adherence to standard precautions: are hospital-based health care provider still at risk Occupational risk of human immunodefciency virus infection in healthcare work ers: an overview. Guidelines for prevention of transmission of human immunodefciency virus and hepatitis B virus to health-care and public-safety workers. ProgressProgress toward the elimination oftoward the elimination of hepatitis B virus transmission among health care workers in the United States. Are universal precautions effective in reducing the number of occupational exposures among health care workers

Taxonomy codes play a critical role in the claims payment process for providers practicing in more than one specialty women's health kissing tips purchase dostinex with mastercard. For assistance in billing the taxonomy code in claim transactions menstruation puns purchase dostinex 0.5 mg line, refer to your practice management software and/or clearinghouse guides breast cancer 70007 dostinex 0.5 mg low price. The numbers in the instructions correspond to the numbers on the form and represent the National Standard Specifications for electronic processing women's health issues statistics order 0.5mg dostinex. Rental Charge (but not to exceed the total cost of purchase) or at the option of the Plan, the purchase of Durable Medical Equipment. Repair, adjustment, or replacement of components and accessories necessary for effective functioning of covered equipment. However, the rental of any equipment should not extend more than 10 months duration. If the prescription indicates lifetime need, the supplier should attempt to sell the equipment as opposed to renting. Predetermination for coverage is recommended for medical necessity determination in order to determine benefit coverage. Providers can fax completed Predetermination Forms to 1-888-579-7935 for urgent requests. Precertification merely confirms the Medical Necessity of the service or admission, but does not guarantee payment. Prescription these guidelines apply to fully insured members as well as self-funded or Certificate employer groups who have opted to follow these guidelines. However, this may of Medical not apply to members with Federal Employee Plan benefits or those from other Necessity, Blue Cross and Blue Shield plans. Note: All services/drugs that will be administered must be listed in the authorization or they will be denied. Home the per diem for aerosolized drug therapy (S9061) does not include the cost Infusion of the nebulizer. Specific services requiring preauthorization as well as information on how to preauthorize services with eviCore are outlined on the Preauthorizations/Notifications/Referral Requirements Lists and on the eviCore Preauthorization Program page on bcbstx. Services performed without preauthorization or that do not meet medical necessity criteria may be denied for payment, and the rendering provider may not seek reimbursement from the member. This Preferred arrangement excludes lab services provided during emergency room Provider visits, inpatient admissions and outpatient day surgeries (hospital and free standing ambulatory surgery centers). Claims that do not comply with these requirements will not be considered for prompt pay penalty eligibility. For submission of paper claims, mail to the following address: Blue Cross and Blue Shield of Texas P. Enter the name, address, city, state and zip code of the party responsible for the bill. If applicable, enter the pre authorization for treatment code assigned by the secondary and tertiary payer (63b and 63c). The 23rd line contains an incrementing page and total number of pages for the claim on each page, creation date of the claim on each page, and a claim total for covered and non-covered charges on the final claim page only indicated using Revenue Code 0001. Occurrence All accident, emergency and maternity claims require the Code/Date appropriate occurrence code and the date. Late It is important to use the correct type of bill when billing for a late Charges/ charge or a corrected claim. Corrected For inpatient 117 corrected claim Claims For inpatient 115 late charges For outpatient 137 corrected claim For outpatient 135 late charges Corrected claims and late charges can be filed electronically. If the corrected claim must be filed on paper it should be submitted with a Corrected Claim Review Form. Preadmission Preadmission tests provided by the Hospital within three (3) days Testing of admission should be combined and billed with the inpatient claim. Pre-Op Tests For outpatient day surgery, services would be billed as one claim to include the day surgery and the pre-op tests. Diabetic Diabetic education must be administered by or under the direct supervision Education of a physician. The Program should provide medical, nursing and nutritional assessments, individualized health care plans, goal setting and instructions in diabetes self-management skills. The V code for the education/counseling would be listed as the secondary diagnosis. To ensure accurate processing, claims received electronically should include the full 11-digit member number. Claim review requests must be submitted in writing on the Claim Review Form form located later in this manual. At the time the claim review request is submitted, please attach any additional information you wish to be considered in the claim review process. If you need to submit a corrected claim, you should submit it electronically or if you must submit paper, it should include a Corrected Claim Form. These forms can be found under Forms under the Education and Reference section on the bcbstx. Mail the Claim Review form, along with any attachments, to the appropriate address indicated on the form. The 2 claim review must be requested st within 15 days following your receipt of the 1 claim review determination. If you do not have the cover sheet please use the Additional Information Form located at bcbstx. Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association Blue Cross, Blue Shield and the Cross and Shield Symbols are registered service marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans. The information is located under the Education & Reference Center tab/Forms section. Credit Payment has been received under two different Blue Cross memberships or from Blue Cross and another carrier. Electronic this on-line refund management tool will help simplify Refund overpayment reconciliation and related processes. If you do not Availity know who your Primary Access Administrator is, click on Who Users controls my access

Feeling blue or sad is a normal reaction to the diagnosis of cancer and the treatment demands womens healthcare associates boca raton dostinex 0.25mg. The illness may also require changes in family routine and bring feelings of social isolation women's health center flint mi order dostinex paypal. You may notice symptoms of grief women's health clinic erina order dostinex mastercard, such as crying spells women's health center hilo cheap dostinex 0.5 mg overnight delivery, decreased appetite or compulsive eating, lack of interest, decreased energy, lack of concentration, poor problem solving, and physical symptoms such as tightness in the chest or headaches. With the support of family, friends, and the health care team, most parents are able to work through these emotions and use coping skills that are needed to meet care demands. Individual or family counseling allows parents a way to discover their inner strengths. Sometimes parents fnd that their emotions are so overwhelming that they feel they cannot cope with the demands being placed on them. When other life stressors, such as loss of a job, moving, marital problems, divorce, emotional problems, or substance abuse existed prior to the diagnosis, the situation may be more diffcult. It may help to discuss your feelings with a trusted member of the health care team. Sharing responsibilities reduces the gap that may grow between parents when one is more involved in care than the other. Suggest specifc ways that they can help you, such as asking them to shop for groceries, cook, clean, or take your other children to and from school. This will save you from repeating the same information over and over to many different people. Some families fnd it helpful to set up a website, blog, or other method of electronic communication to keep others informed. Parents often become exhausted trying to cope with the needs of the child and the rest of the family; fnancial problems are common. Many parents try to continue to work at their jobs and keep the home routine as normal as possible. Three things may help prevent the breakdown of a marriage/relationship: respecting coping styles, maintaining communication, and accepting changing roles. Some parents may withdraw, others may cry or get angry, while others may cope by gathering information. Maintaining Communication the key to any successful relationship is communication. By sharing feelings and information you can stay connected and be better able to make decisions. Accepting Changing Roles the demands of illness and treatment can change the roles of family members. Some role changes may become permanent, if the changes help improve how parents or family members work together. The most important thing to help is to stay focused on your ill child and their brothers and sisters. Family boundaries and routines can become blurred when separated or divorced parents pull together to care for their child after diagnosis. In stepfamilies, it is important for stepparents to allow biological parents time and space to work together to make treatment decisions and to care for the ill child. It is important to remain fexible and supportive of each other so that you can deal with needed changes to your parenting plans as your child begins treatment. If your relationship with your ex is diffcult, you may want to seek additional help from your social worker or psychologist to help cope with your feelings. In addition, your child with cancer and your other children may need additional support to cope with these added changes to their family, especially if the separation or divorce recently occurred. Though the marriage or relationship has ended, your responsibility for parenting continues. While your other children may feel sad and worried about their sick brother or sister, they may also feel some resentment or anger. Often brothers and sisters have problems of their own, such as depression, trouble sleeping, physical complaints, or problems in school. Assure them that cancer is not contagious and they are not responsible for their brother or sister getting cancer. This may help to decrease their fears and increase feelings of closeness with their brother or sister. Teachers can be supportive to your children and let you know about any school-related problems. They may also feel they are responsible, and may worry that they in some way passed cancer through the family. Grandparents may also feel sadness, not just for their grandchild, but for their son or daughter as well. If they are in good health and can be with you, they can relieve you in the hospital or help you at home. A grandparent may also give your other children the attention, comfort, and love that they need. Including grandparents in meetings with the health care team can help them to understand the plan of care for their grandchild. Children can get used to being special and want the special treatment to continue. Discipline problems are most common when the special attention stops and normal activities resume. These behavior changes can make it diffcult to know what is reasonable to expect of your child. If a parent is too lenient, the child may think the illness is worse than they have been told. If your child is not feeling well, please and thank you may not be reasonable with every request. Resources Many resources are available at your hospital and clinic and in your community to help your child and family through this time. Types of resources available may include information, support, fnancial assistance, housing, and transportation. The health care team needs you to let them know what types of resources would be most helpful to you. If you have questions about what you read on any of the sites, please ask someone on your health care team to discuss the content with you. These websites allow patients and families to keep friends and loved ones informed, and to receive messages of encouragement and support. Families have control over website privacy levels, including an option to set a site password or approved visitor list. A search within the portal can be customized by user, the disease or condition, and the age group of the patient. For more information about resources in your area, refer to the Information from My Hospital section of this handbook, or ask your health care team. Finishing treatment can be an unsettling time and you may be surprised you are not feeling the joy you thought you would.

Hard copies of the plan should be distributed to all response and supporting agencies and should be available electronically if possible breast cancer xrays generic 0.25 mg dostinex. Clear triggers for the activation womens health 28 day challenge best dostinex 0.25 mg, escalation and deactivation should be written into the plan and reviewed as required breast cancer 30s dostinex 0.25mg fast delivery. As mentioned earlier in this chapter womens health las vegas discount 0.5 mg dostinex, there may be reluctance on the part of public health offcials to implement a dengue emergency response plan until the case count and fatality numbers are elevated. It is recommended that the plan should include objective criteria for defning an epidemic on the basis of specifc local data and not general concepts. While plans have frequently been prepared in dengue-endemic countries, they are seldom validated. Once the dengue emergency response plan has been drafted and approved by participating groups, it is important to conduct simulations or table top exercises. Since the emergency response is usually multisectoral, exercises provide opportunities for all partners to participate and better understand their roles, responsibilities, channels of command and communication, and to ensure the availability of the human resources, equipment and supplies needed for a rapid emergency response. Formal debriefng sessions should take place with the partners after exercises and after epidemics. Educating the community and relevant professional groups about the current proceduresusedfordenguecontrolbytheresponsibleauthoritiesintheirjurisdiction (local, provincial and national governments, as appropriate) as well as their roles and responsibilities in dengue prevention and control. These should include rapid investigation of sporadic cases (clinically suspected or laboratory confrmed) to determine whether they are imported or locally-acquired, monitoring of vectors and their abundance (particularly in regions with recorded or suspected cases), social mobilization, and environmental management efforts. Once a locally acquired case is confrmed, the response may be escalated to epidemic response to prevent further spread and/or interruption of transmission. In countries at risk of the introduction of dengue vectors, the focus of activities may be on entomological surveillance at ports of entry and education of the health care community about the risk of dengue in travellers, and its diagnosis and reporting requirements. It is not possible for a single government agency to control the causes and consequences of dengue epidemics and to protect population health. For this reason it is recommended that countries establish a multisectoral dengue action committee. The committee must have solid funding and a designated national coordinator with the political mandate to make policy and fnancial decisions and to coordinate the multisectoral preparedness and response strategy at local, state and national levels. Depending on the epidemiological situation in each country, membership of the dengue action committee may include, but need not be limited to , heads of government agencies. For countries at lower risk of dengue transmission, the dengue action committee may be constituted within the affected jurisdiction. A major responsibility of the dengue action committee is to develop the dengue emergency response plan, review it regularly, and update it as necessary on the basis of the lessons learned from its implementation or simulation. Some groups need special attention because of their dependence on others who take care of them and their immediate surroundings. If not properly screened or air-conditioned, health care settings may also be at high risk for dengue transmission. Migrant workers living in poorly constructed and maintained facilities can be particularly at risk of the transmission or introduction of dengue. These typically lacked basic community infrastructure, including access to piped water and adequate garbage disposal, and lacked both the organization needed for collective action against the threat of a dengue fever epidemic and the understanding about how they could contribute to preventive actions to mitigate the risk (22). In addition, international trade in, and inadequate disposal of, vehicle tyres similarly provide larval habitats, and international air travel results in the movement of viraemic individuals and vectors over long distances. Increased international travel and trade provide ideal means for infected human transport of dengue viruses and/or vectors, resulting in a frequent exchange of dengue viruses among endemic countries, the risk of dengue introduction to receptive areas, and the spread of vectors into new ecological niches. In areas that are highly receptive to dengue, a single imported case can start an epidemic. Because of the risk of a viraemic traveller initiating an outbreak, surveillance for clinical cases of dengue is very important since it enables action to be taken promptly to reduce the risk of local transmission. Countries should undertake a dengue risk assessment as the basis for preparedness plans. Surveillance, emergency preparedness and response thus avoid introducing costly and demanding measures that are not justifed by the epidemiological situation. It is imperative that medical and nursing staff understand the rationale and priorities for patient care under epidemic conditions. The principal burden that dengue epidemics create for affected countries is not the number of deaths but the enormous number of hospitalizations and days of illness. Providing care for an elevated number of dengue cases requires criteria for triage, trained physicians and nursing personnel, beds, supplies and equipment, and training guidelines for treatment and patient isolation. Isolation refers not only to routine precautions for manipulation of blood and other body fuids but also to the use of (insecticide treated) mosquito nets to prevent mosquitoes from biting viraemic (febrile) patients and subsequently spreading the virus within the community. It is essential to train professionals in the early detection of cases and to educate the community to seek medical attention when dengue symptoms appear. Planning for suffcient provisions during a dengue epidemic can be guided by hospitalization rates in previous outbreaks. A weakness of some current dengue prevention strategies is that they are reactive rather than anticipatory. They may often be implemented late, thus reducing the opportunities for preventing transmission and controlling the epidemic. In general, such reactive strategies lead only to short-term behavioural change and fail to institutionalize the idea of community and personal responsibility for dengue prevention and control in partnership with government efforts. Public education must continue to reinforce how important it is for people to seek medical attention if they have dengue symptoms, and should stress the need to reduce larval habitats and the options for personal protection. During an epidemic the aim of public risk communication, generally through the media, is to build trust. It does this by announcing the epidemic early, providing accurate information, communicating openly and honestly with the public (transparency), and 127 Dengue: Guidelines for diagnosis, treatment, prevention and control providing specifc information about what people can do to make themselves and their community safer. This gives people a sense of control over their own health and safety, which in turn allows them to react to the risk with more reasoned responses (25). In endemic countries, involving the media before the occurrence of the seasonal increase in dengue enhances the opportunity to increase public awareness of the disease and of the personal and community actions that can be taken to mitigate the risk. Information about an impending increase in the incidence of dengue will provide valuable time to make fnal preparations and implement the contingency plan. The public health community is increasingly observing the implementation of emergency responses to diseases such as avian infuenza in preparation for pandemic infuenza. In areas where a comprehensive surveillance system exists, detailed information about when and where dengue outbreaks/epidemics occurred in the past can be a useful guide to the potential magnitude and severity of future epidemics. If there is no surveillance system in place, the early warning element of the programme and the valuable time needed to make preparations for the response are lost. In such a situation, the emergency may rapidly overwhelm the public health and medical care agencies without warning. It aims to identify strengths and weaknesses in programmatic and public health infrastructure that can reduce or increase vulnerability to respond to dengue. Programme assessment should review areas such as the dengue emergency response plan, human resource planning (including training), the effectiveness of the dengue surveillance system in providing early warning, the effectiveness of the vector control programme, laboratory capacity, stockpiling and applied research needs (26). In order to develop a meaningful preparedness plan during the inter-epidemic period, it is important to estimate the population at risk, expected admission rates, the equipment, supplies and personnel required for vector control and patient management, and to document the location of resources. Many health care providers fail to report dengue activity until they receive a positive laboratory diagnosis because they are unaware that prompt vector control measures can be initiated as soon as suspected cases are notifed. Some doctors may not request tests during an outbreak because they may be confdent of their ability to diagnose dengue clinically. Other doctors may not be aware of the value of laboratory confrmation or may not be familiar with the tests available, the timing of 128 investigations, and the problems inherent in interpreting laboratory results when more Chapter 5. Surveillance, emergency preparedness and response than one favivirus is circulating or the patient has been exposed to dengue or other faviviruses in the past. Physicians, nurses and laboratory staff should receive regular clinical training in the management of dengue patients. Clinicianseducation in the emergency response to a dengue epidemic relates principally to raising awareness of the spectrum of disease and the essentials and complexities of treatment. It is important to emphasize that treatment of dengue consists of appropriate hydration and the administration of paracetamol/acetaminophen to control pain and fever (never acetylsalicylic acid [aspirin]). Physicians must be able to distinguish between typical and atypical dengue syndromes, and access to laboratory diagnosis is useful.

American Academy of Pediatrics Committee on Pediatric Emergency Medicine menstruation hygiene buy generic dostinex 0.25mg online, American College of Emergency Physicians Pediatric Committee menstruation videos for kids order 0.5mg dostinex fast delivery, Emergency Nurses Association Pediatric Committee menstruation during early pregnancy purchase generic dostinex line. Death pregnancy yolk sac purchase dostinex 0.25mg online, child abuse, and adverse neurologic outcome of infants after an apparent life-threatening event. Abusive head trauma in children presenting with an apparent life-threatening event. Time saved with use of emergency warning lights and sirens during response to requests for emergency medical aid in an urban environment. Apparent life-threatening event: multicenter prospective cohort study to develop a clinical decision rule for admission to the hospital. Do infants less than 12 months of age with an apparent life-threatening event need transport to a pediatric critical care center Availability of pediatric services and equipment in emergency departments: United States, 2002-03. A clinical decision rule to identify infants with apparent life threatening event who can be discharged from the emergency department. Mortality and child abuse in children presenting with apparent life threatening events. Apparent life threatening events in infants: high risk in the out-of-hospital environment. Revision Date September 8, 2017 136 Pediatric Respiratory Distress (Bronchiolitis) (Adapted from an evidence-based guideline created using the National Prehospital Evidence-Based Guideline Model Process) Aliases None noted Patient Care Goals 1. Promptly identify respiratory distress, failure, and/or arrest, and intervene for patients who require escalation of therapy 3. Deliver appropriate therapy by differentiating other causes of pediatric respiratory distress Patient Presentation Inclusion Criteria Child 2 yo typically with diffuse rhonchi or an otherwise undifferentiated illness characterized by rhinorrhea, cough, fever, tachypnea, and/or respiratory distress. Hydration status (+/ sunken eyes, delayed capillary refill, mucus membranes moist vs. Give supplemental oxygen escalate from a nasal cannula to a simple face mask to a non-breather mask as needed, in order to maintain normal oxygenation b. Suction the nose and/or mouth (via bulb, Yankauer, or suction catheter) if excessive secretions are present 4. Inhaled medications nebulized epinephrine (3 mg in 3 mL of normal saline) should be administered to children in severe respiratory distress with bronchiolitis. Steroids are generally not efficacious, and not given in the prehospital setting 7. Bag-valve-mask ventilation should be utilized in children with respiratory failure 8. Supraglottic devices and intubation should be utilized only if bag-valve-mask ventilation fails b. The airway should be managed in the least invasive way possible Patient Safety Considerations Routine use of lights and sirens is not recommended during transport. Suctioning can be a very effective intervention to alleviate distress, since infants are obligate nose breathers 2. Heliox should not be routinely administered to children with respiratory distress 3. Insufficient data exist to recommend the use of inhaled steam or nebulized saline 4. Though albuterol has previously been a consideration, the most recent evidence does not demonstrate a benefit in using it for bronchiolitis 5. Ipratropium and other anticholinergic agents should not be given to children with bronchiolitis in the prehospital setting 6. Rate of administration of accepted therapy (whether or not certain medications/interventions were given) 4. Change in vital signs (heart rate, blood pressure, temperature, respiratory rate, pulse oximeter, capnography values) 5. Nasal continuous positive airway pressure decreases respiratory muscles overload in young infants with severe acute viral bronchiolitis. Short acting beta2-agonists for recurrent wheeze in children under two years of age. A prospective multicenter evaluation of prehospital airway management performance in a large metropolitan region. Pediatric myocarditis: emergency department clinical findings and diagnostic evaluation. A randomized trial of nebulized 3% hypertonic saline with epinephrine in the treatment of acute bronchiolitis in the emergency department. Time saved with the use of emergency warning lights and siren while responding to requests for emergency medical aid in a rural environment. Non-invasive ventilation as primary ventilatory support for infants with severe bronchiolitis. Clinical practice guideline: the diagnosis, management, and prevention of bronchiolitis. A prospective in-field comparison of intravenous line placement by urban and nonurban emergency medical services personnel. Steam inhalation or humidified oxygen for acute bronchiolitis in children up to three years of age. Revision Date September 8, 2017 141 Pediatric Respiratory Distress (Croup) (Adapted from an evidence-based guideline created using the National Prehospital Evidence-Based Guideline Model Process) Aliases None noted Patient Care Goals 1. Promptly identify respiratory distress, respiratory failure, and respiratory arrest, and intervene for patients who require escalation of therapy 3. Deliver appropriate therapy by differentiating other causes of pediatric respiratory distress Patient Presentation Inclusion Criteria Suspected croup (history of stridor or history of barky cough) Exclusion Criteria 1. Mental status (alert, tired, lethargic, unresponsive) 142 Treatment and Interventions 1. Escalate from a nasal cannula to a simple face mask to a non-breather mask as needed, in order to maintain normal oxygenation b. Suction the nose and/or mouth (via bulb, Yankauer, or suction catheter) if excessive secretions are present 3. Heliox for the treatment of croup can be considered for severe distress not responsive to more than 2 doses of epinephrine b. Bag-valve-mask ventilation should be utilized in children with respiratory failure 7. Supraglottic devices and intubation supraglottic devices and intubation should be utilized only if bag-valve-mask ventilation fails. The airway should be managed in the least invasive way possible Patient Safety Considerations 1. Patients who receive inhaled epinephrine should be transported to definitive care Notes/Educational Pearls Key Considerations 1. Foreign bodies can mimic croup, it is important to ask about a possible choking event 3. Without stridor at rest or other evidence of respiratory distress, inhaled medications may not be necessary 143 Pertinent Assessment Findings 1. Document key aspects of the exam to assess for a change after each intervention: a. Frequency of administration of specified interventions in the protocol References 1. Pediatric myocarditis: Emergency department clinical findings and diagnostic evaluation. Effect of out-of-hospital pediatric endotracheal intubation on survival and neurological outcome. Use of helium-oxygen mixture to relieve upper airway obstruction in a pediatric population. Initial oxygen saturation as a predictor of admission in children presenting to the emergency department with acute asthma. Use of racemic epinephrine, dexamethasone, and mist in the outpatient management of croup. Controlled delivery of high vs low humidity vs mist therapy for croup in emergency departments: a randomized controlled trial. Revision Date September 8, 2017 146 Neonatal Resuscitation Aliases None noted Patient Care Goals 1. Provide appropriate interventions to minimize distress in the newly born infant 5.

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