I have a student that has severe asthma. When she has an attack, I immediately give her a nebulizer treatment which is the only medication that I have in my clinic. Let me tell you, her attacks are scary! She wheezes, has contractions and my pulse ox reader normally registers her O2 at 94-95%! After treatment, contractions and wheezes are gone but her O2 usually doesn't get much higher than 97%.
Last week, she came in for a treatment in the early morning but returned an hour later, having another attack. Mom was working as a sub so I immediately paged her. After an assessment I offered to call 911 but mom was hesitant. Mom did give her an inhaler, and it helped a little bit. I called her pediatrician because I knew she needed help but I didn't want to overstep mom and call 911 without her permission. I'm a new school nurse and still get anxious about those kind of things...
Long story short, Mom took her to the pediatrician after the student calmed down a big and she was admitted to the hospital for a couple of days. Mom stopped by the clinic this morning with an update and informed me that the next time this happens, I need to call 911 immediately, not her but 911. I was taken back seeing how I suggested that last week and she said no.
Anyways, I'm curious when would you call 911 for an asthmatic patient? I don't want to be put in that situation again. Now thinking about it, I feel like I should call 911 on her initial attacks because they are so bad! Help..new school nurse and I'm second guessing everything!
Specializes in ICU/community health/school nursing.
3 hours ago, EnoughWithTheIce said:
Personally, I would have stood my ground. "Mom, based on my assessment, your child needs immediate evaluation. We can call 911 or you can transport him / her to the ER immediately. What is your choice?"
I love this verbiage. ANd I know that you document that very thing, too. See, OP - we all learned a thing today. And next time you'll do it differently and with confidence, right?
Specializes in ICU, ER, Home Health, Corrections, School Nurse.
As previously mentioned, the Pso2's aren't always a reliable indicator. One of the tools I use is the 1-10 indicator: One is perfect, ten is you're really scared something bad is going to happen. Establishing a numeric baseline is very helpful i.e. if they go from 5 to 8 it's 911 time. Asthma is tricky because kids who are used to wheezing may show no distress whatsoever. Yet the ones who come in so tight that they are NOT wheezing, can decompensate very quickly. I recently had an asthmatic who's sats never dropped below 98% but she was so short of breath she was starting to have visual disturbances. 911 time.
Specializes in Adult and pediatric emergency and critical care.
What you're describing doesn't really sound like a "severe" asthma attack, but that isn't really the point. If you feel that there is an emergency that you cannot safely control you should be calling 911. The mother can refuse treatment or transport if appropriate. Back when I was on the fire service we used to get calls from the elementary schools for asthma quite a bit. The kids almost always got nebs from us, and sometimes got steroids. I'd say half the time the kid looked substantially better and could stay at school and half the time we would take them in.
This does sound like a very poorly managed asthma patient. Albuterol is not a controller, it is a rescue med. This kid should have an asthma action plan and you should have a copy of it, but more importantly this kid needs to have better controllers. Whether this means an inhaled steroid, long term dialator like formoterol, biologics, histamine blockers, and so on. It is not appropriate for a kid to be regularly dependent on albuterol, that is a huge flag of poor management.
As far as nebs compared to MDIs, the latter can work as well as nebs in some situations but only if used with a spacer. The dose of a neb is still substantially higher, but it also needs to be on an appropriate setup at the correct pressure and flow. Hands down you can give more medication by nebulizer than inhaler. There is a good chance that the albuterol you gave by neb was still kicking in when the mom gave a MDI dose, I doubt 90 mcgs opened her up rather than the 2500 mcgs you just gave. There are many times that MDIs are all the patient needs, but that doesn't mean that they provide the same dosing.
Pulse oximetry is a pretty poor sign of asthma severity. Those in extremis can still have a decent saturation if they are clamped down, and those who open up and are doing great can have a temporary saturation dip from VQ mismatch and be just fine. I would focus on work of breathing and peak flow more than pulse ox, these are a far better representation of their acuity and disease process. Also keep in mind that severe asthma may present without wheezing, and that wheezing can be caused by other disease processes besides bronchoconstriction.
We use a Clinical Respiratory Score rubric and you get either a 0, 1 or 2 in 6 categories. The highest score is a 12 with 8-12 being considered severe to life threatening. A sat of 90-95% gets you a 1. So I agree that it is an overall picture and not just one thing. I also agree - if you think about 911 then go with your gut.
Would you care to share the rubric you use? Most are so cumbersome and require tools that I do not have in my health room.
I have not worked as a school nurse, but have worked in urgent care and pediatric urgent care.
When I had to call 911 and the parent did not want me to call 911, I told the parent that THEY could decline transport but that I and the providers present felt it necessary for more serious intervention. CYA. That way it was in my notes, the provider's notes, 911 logs, and paramedic's documentation. I can only think of two times when the parent still declined. We used to follow up on all kids the next day and one kid was fine while the other was in the PICU. Don't know what happened after that.
Any child under respiratory distress absolutely needs to go via 911 to the ER. Basically, unless the mother was strongly refusing any ER transfer, you document AMA and EMS refusal...and then get your advanced airway/CPR ready....
PeakRN covered a lot of the "extra" clinical pearls that I talk about when I teach PALS. (and the need for maintenance meds!) Rate and WOB always carry more weight with me than pulse ox- especially since I can't bring myself to 100% trust the equipment we have. I trust a nellcor or nonin unit that gets checked by biomed regularly but use a grain of salt with a fingertip unit from amazon or even school nurse supply that has been in the drawer for 8 years. That comes down to the general "treat the patient, not the monitor" mantra.
I will add - I have a student with frequent asthma flare-ups. She can sat at 98% and drop like a rock a moment later. One day, I was called to assess her in the classroom. She could not get out a sentence without coughing. Had used inhaler >5 minutes before. My gut instinct red flag went up and I called 911 before I even checked a sat.
Sat was 98%, FYI. Paramedics treated me like I was crazy, but I knew this kid. Out she went and was admitted for 2 days - O2 also dropped like a rock right after arriving at ER.
Had this student been able to sit and talk to me without coughing, my action may have been different. I was also pretty familiar with this student, their asthma presentation, and their action plan. O2 Sat is just one data point of many. Whoever said said get an asthma action plan - that would be important for me going forward.
I have not worked as a school nurse, but have worked in urgent care and pediatric urgent care.
When I had to call 911 and the parent did not want me to call 911, I told the parent that THEY could decline transport but that I and the providers present felt it necessary for more serious intervention. CYA. That way it was in my notes, the provider's notes, 911 logs, and paramedic's documentation. I can only think of two times when the parent still declined. We used to follow up on all kids the next day and one kid was fine while the other was in the PICU. Don't know what happened after that.
Just my two cents.
The same argument I use with a sick staff member.
"YOU can make that decision when EMS arrives and gives you their assessment. I am using my best professional judgement here"
I will add - I have a student with frequent asthma flare-ups. She can sat at 98% and drop like a rock a moment later. One day, I was called to assess her in the classroom. She could not get out a sentence without coughing. Had used inhaler >5 minutes before. My gut instinct red flag went up and I called 911 before I even checked a sat.
Sat was 98%, FYI. Paramedics treated me like I was crazy, but I knew this kid. Out she went and was admitted for 2 days - O2 also dropped like a rock right after arriving at ER.
Had this student been able to sit and talk to me without coughing, my action may have been different. I was also pretty familiar with this student, their asthma presentation, and their action plan. O2 Sat is just one data point of many. Whoever said said get an asthma action plan - that would be important for me going forward.
Way to go!! We need @OldDude over here to give you some praise.
I think it's a good idea to think of one other reason to NOT "delay" calling 911...They do a fantastic job but they aren't ALWAYS available upon your call. I remember calling 911 to the Urgent Care clinic I work at for a kid who had some of the worst retractions I've seen. All the city EMS units were tied up and EMS from another town had to be dispatched...35 minute response time. That's a long time when the kid is teetering at the edge of the abyss.
ruby_jane, BSN, RN
3,142 Posts
I love this verbiage. ANd I know that you document that very thing, too. See, OP - we all learned a thing today. And next time you'll do it differently and with confidence, right?