Asthma Clinical Pathway — Emergency Department

Emergency Department Clinical Pathway for
Evaluation/Treatment of Children with Asthma

Metrics
Patient Education
Provider Resources
Child with Asthma and Respiratory Complaint
 
 
Triage
RN Standing order for dexamethasone ESI 2-3
 
 
 
 
ED Team Assessment
Determine Severity Level (PASS)
 
 
 
 
 
 
Mild
ESI Triage 4
Moderate
ESI Triage 3
Severe
ESI Triage1-2
  • Dexamethasone tablet, all ages
  • Albuterol MDI weight-based q20min x 3 PRN
  • Dexamethasone tablet
    • Alternative: IM dex/ IV methylpred
  • UniNeb: albuterol + ipratropium
  • Unable to tolerate mask:
    • MDI with albuterol + ipratropium
  • Consider IV magnesium
  • Consider SubQ terbutaline
 
 
 
 
Assess after completion of β-agonist
Considerations for Further Diagnostic Testing
Supplemental oxygen for persistent SpO2 < 90%
Critical/Impending Respiratory Failure
 
 
 
 
Mild-Moderate
Severe
Attending eval at bedside
  • Hold treatment
  • Observe
    • Initial moderate: 1 hr
    • Initial severe: 2 hrs
  • 2nd albuterol neb x1 hr
  • Consider IV magnesium
 
 
 
 
Reassess
Allow ≥ 2 hrs for steroid effect before disposition
 
 
 
 
 
 
Mild
Moderate
Severe
  • Q2hr albuterol
  • Admit EDECU if available
  • Continuous albuterol
  • Admit
Albuterol Weight-Based Dosing
Kg Unit Dose (0.5%) MDI Puffs Continuous (1 hr unineb)
5-10 2.5 mg (0.5 mL) 4 7.5 mg/hr
> 10-20 3.75 mg (0.75 mL) 6 11.25 mg/hr
> 20 5 mg (1 mL) 8 15 mg/hr
Ipratropium Weight-Based Dosing
Kg Unit Dose (0.02%) MDI Puffs
5-10 500 mcg over 1 hr in UniNeb or 250 mcg q20 min x 2 4
> 10-20 1000 mcg over 1 hr in UniNeb or 500 mcg q20 min x 2 6
> 20 1000 mcg over 1 hr in UniNeb or 500 mcg q20 min x 2 8
Steroids
Dexamethasone
  • Mild-moderate flare, repeat in 24-48 hrs
  • Crush tablet with cherry syrup, juice or yogurt
    • 5-8 kg: 4 mg
    • > 8-12 kg: 6 mg
    • > 12 kg: 8 mg
Prednisone/ Methylprednisolone 2 mg/kg PO/IV, Max 60 mg
Escalation Medications
Magnesium Sulfate
  • 50 mg/kg, Max 2 g
  • Give with normal saline bolus, 20ml/kg, Max 1 liter
  • q15min VS, observe in ED 60 min before transfer to inpatient floor
Terbutaline
  • Intermittent IV dose preferred
    Repeat as needed q15-30min, Max of 3 doses
    • Intravenous:
      Infuse over 5 mins, 10 mcg/kg, Max 250 mcg
    • Subcutaneous:
      10 mcg/kg, Max 250 mcg
  • IV Infusion
    • Not generally recommended in ED
    • Bolus: 10 mcg/kg, Max 400 mcg
    • Continuous Infusion as indicated
      • Start at 0.4 mcg/kg/min
      • Titrate to max 3 mcg/kg/min
Posted: October 2005
Last Revised: March 2025, Revisions
Editors: Clinical Pathways Team