Asthma attacks without an inhaler

[PCP]

As a first aider I can administer ventoline by using a puffer which we carry on all three of our jump kits. We have a medical director and when I first started by boss paid for me to go over to Vancouver and take a 1 day course which gave me certification to administer ventoline via inhaler. We can alos administer other meds. as well through this 1 day course.

Does your company have a medical director?

Is there any courses where you live that you can take which give you the certification to administer certain medications as a first aider?

When it comes to using another persons puffer I would probably not use it as it does not follow the 6 R of medication use ( if I was a first aider in town and I knew that an ambulance could be there within minutes.) When you are an hour and a bit from town sometimes you have to go outside of the lines and if that means using some other person's medication to help this person, than I guess I would possibly loose my license.

I know that if we did not carry inhalers and someone was suffereing from Asthma and somebody offered their inhaler and I said " No" I am not allowed to use other peoples meds. and this person died! I could not look myself in the mirror knowing I could have done something to help but didn't because of some Rules and Regulations!

I am a strong believer in helping people in need no matter what the outcome could mean for me!

Brian

[chbare]

This discussion seems to be based on the ever popular "How far would you go to save a life" principle, i.e. would you bend or break the rules if it was to save a life. This is a philosophical discussion that involves ethical dilemmas that transcend medical, legal, and political philosophy. Its a sticky situation, along the lines of jailing a man for stealing a loaf bread to feed his family etc. etc. etc.

Luckily, in this case, it is not at all relevant. At all. The reason being is because as my post mentioned before, MDI's are NOT a life saving intervention, but rather for therapeutic relief of mild asthma symptoms. In other words, if you have an asthmatic who is wheezing and improves on oxygen, they don't need an MDI immediately. On the other hand, if you have an asthmatic who is not improving on oxygen and is barely moving air, they don't need an MDI, they need a BVM and immediate transport. This should render the entire premise of this argument null and void.

Unless someone can provide literature detailing the deterioration of an asthmatic on a timeline that reasonably exceeds standard transport times with only an MDI as the mediator, again, I say, this is a non-argument.

If somebody improves on oxygen, I will still assess their PEFR. If it is low, I will treat regardless of an "improvement" on oxygen since oxygen does not reverse airflow obstruction. Also, using an MDI with a spacer may have similar efficacy to low volume nebulised delivery. Since albuterol is considered a rescue medication, it may be life saving in that it can potentially prevent further exacerbation. Remember, a patient can present with an unremarkable physical exam only to have a critically low PEFR and significant airflow obstruction.

[ERDoc]

A little off topic, but chbare, I wish you could work at my shop. I can't tell you how many times, after ordering a neb, I hear, "Well, I didn't give it to him because he wasn't wheezing."

[Asysin2leads]

I think you're missing the point. An MDI will prevent further exacerbation. I'm not talking about a person with a fully equipped ALS bus. In that case, a nebulizer is the correct course of action. This isn't the situation that is being described. What is being debated is whether a non-prescribed MDI should be used in the absence of a prescribed MDI. In that case, the answer is no, the MDI is not going to have an immediate life saving effect. It will not be the difference between life and death. Now for any circumstance, you could create a scenario that would fit your needs. I'm sure if you stop an asthmatic from using an MDI, on a long enough time line, they will get into trouble. But exactly what situation are we talking about? Exactly where are you that you have many people ready to hand you an inhaler, but your transport time to the hospital is in such excess that a person experiencing asthma symptoms that at upon your arrival can be relieved with a simple MDI, but will degenerate enroute to the point of being critical? If the person is at a point where there is a real and present danger of decompensation secondary to status asthmaticus during your transport, they are going to need much more than a simple MDI, even with a spacer, to save their life. In the movies someone is in danger of dying because they can't get to their MDI. In real life its more complicated. In fact, by definition, status asthmaticus, that thing that actually kills you, is a prolonged asthma attack that does not respond to bronchodilators. Now I suppose an asthmatic could have been in an asthma attack for long enough that they have merely tired out their diaphragm and accessories, but will still respond to a bronchodilator, but again, in that case, a simple MDI is not going to make much of a difference. They're still exhausted.

Now ER doc, I'm not sure what situation you're talking about where someone who need a nebulizer didn't get one because of the absence of wheezing, but if you're referring to silent chest, aren't they pretty much past the point of using a simple nebulizer? Isn't that usually when someone is making a call to anesthesia to pop down to the ER with their tools?

[ERDoc]

Asys, I was going off topic with chbare, sorry about that. Our RTs don't believe in albuterol unless there is wheezing. I use it in pts with cough/sob (not talking silent chest) for symptom relief. Think someone with bronchitis. It just rubs me the wrong way when they cancel my order and don't bother telling me. Anesthesia is for wusses.

[chbare]

I just wanted to emphasise a few points. For example, oxygen will not be all that helpful. In fact, in some cases, we may administer a mixture of 20-30% mixture Oxygen and 70-80% Helium while we try to decrease obstruction with other methods. Also, the absence of wheezing is not always this disastrous silent chest everybody assumes. A person can present with relatively milld symptoms and no wheezing, only to have significant airflow obstruction. This may not even be appreciated until you assess the PEFR and even perform bedside spirometry and you note a significant ice-cream scoop on the flow/volume loop. Asthma is much more complicated and subtle than many assume.

My post was not necessarily related to the topic at hand. If somebody is having trouble with their asthma and I just happen to be a first aider, I will most likely call an ambulance, provide emotional support, obtain a history and transfer my findings to the EMS crew. All this craziness about giving this MDI or that MDI to a patient is not all that relevant as you have pretty much stated. Perhaps, it would apply in some rural situations or outlandish disaster scenarios, but for the most part, I'll wait for EMS.

ERDoc, I am not a huge fan of cancelling orders. While I do believe inhaled bronchodilators are over utilised in the hospital and outside of the hospital, I would need to present a solid case before cancelling an order and I don't believe in going behind a physicians back. What I am not keen on is arbitrarily ordering scheduled bronchodilators on patients. However, I don't necessarily use the absence of wheezing to determine the absence of obstruction. For example, I have mild to moderate obstruction and had likely gone 30+ years with asthma until I was diagnosed a few years back during a PFT. I had crap peak flows and air trapping without any wheezing, but for years I would cough and often clear my throat. I didn't really know how bad I felt until I was treated.

[tniuqs]

www.rcsw.org/.../Presentation%202005%20Aero%20WashState05.ppt

Slide #15 ... Rubilar L, et al. Pediatr Pulmonol 200;29:264-269

ED based, 123 patients presenting with moderate-severe wheezing

Most < 12 months age

NEB - .25mg/kg salbutamol Q13 min x 3

MDI+VHC- 2 puffs salbutamol Q10 min x 5

Successful clinical response

After 60 mins: 91% MDI , 71 % NEB

After 120 mins: 100% MDI, 94% NEB

I think you're missing the point. An MDI will prevent further exacerbation. I'm not talking about a person with a fully equipped ALS bus. In that case, a nebulizer is the correct course of action.

Yes and No .. see the studies MDI with Spacer vs SVN but staying on topic, (because the bystander did not HAVE a SVN) the scenario is very open ended sure and an Ambulance should be dispatched. Here in Alberta due to long response times (due to a premature death in a place called Morinville AB, and recommendations from a medical fatalities inquiry) We have through "gap" training permitted the EMT level to administer Ventolin/Salbutamol via standing orders its just the RIGHT thing to do. So welcome to Canada Asysin2leads .. their IS a cultural difference and this would be one of them .. chillax no one is going to sue you, as an ACP in BC you will have a lot more "influence" than you had in the US.

This isn't the situation that is being described. What is being debated is whether a non-prescribed MDI should be used in the absence of a prescribed MDI. In that case, the answer is no, the MDI is not going to have an immediate life saving effect.

Hello .. the patient "identified" that she (age unknown) left her "puffer" at home well thats good enough for this crazy cowboy). My first question (not leading the patient is what colour is your puffer) .. so if you have to fall back to a mnemonic the "right" patient, you have right patient AND all MDI are similar dosage 100 mcs per (do the body wt math)... so what's the rest of the silly mnemonic ?

It will not be the difference between life and death. Now for any circumstance, you could create a scenario that would fit your needs. I'm sure if you stop an asthmatic from using an MDI, on a long enough time line, they will get into trouble.

Oh yes it could develop into something life threatening ! but your second statement is contradictory.

But exactly what situation are we talking about? Exactly where are you that you have many people ready to hand you an inhaler, but your transport time to the hospital is in such excess that a person experiencing asthma symptoms that at upon your arrival can be relieved with a simple MDI, but will degenerate enroute to the point of being critical?

Try any summer camp, a church event, boy scouts ... maybe even "youth for anarchy" or "smoke in protest", after all you are in BC !

If the person is at a point where there is a real and present danger of decompensation secondary to status asthmaticus during your transport, they are going to need much more than a simple MDI, even with a spacer, to save positively affect a life or avoid an unnecessary admission to ER or ICU. Asthmatics are a bitch to Intubate and Ventilate !

In the movies someone is in danger of dying because they can't get to their MDI. In real life its more complicated.

Like say on board an aircraft or a ferry ? ... again situational awareness is mandatory. If a unit is 7 mins out, well that's a different ball o wax.

In fact, by definition, status asthmaticus, that thing that actually kills you, is a prolonged asthma attack that does not respond to bronchodilators. Now I suppose an asthmatic could have been in an asthma attack for long enough that they have merely tired out their diaphragm and accessories, but will still respond to a bronchodilator, but again, in that case, a simple MDI is not going to make much of a difference. They're still exhausted.

Not really its Hypoxia, PH imbalances, cardiac collapse ARDS and of course BaroTrauma that are the post mortem results .. i.e. small airway disease secondary to ....

Now ER doc, I'm not sure what situation you're talking about where someone who need a nebulizer didn't get one because of the absence of wheezing, but if you're referring to silent chest, aren't they pretty much past the point of using a simple nebulizer? NO it ain't, try back to back .

Isn't that usually when someone is making a call to anesthesia to pop down to the ER with their tools?

Nope a senior RRT or Respirologist (ps an Intensivist with a full unit) should be paged to ER, not a gas passer unless you need halothane order on a ventilator http://jama.ama-assn...1/20/2688.short

ERDoc is 110% correct AGAIN ... as a "intrinsic asthmatic myself" I get tight / cough / when I develop mild SOB from an upper respiratory viral infection. I used to get "annoyed" treating pneumonia patients in Hospital until I got really (life threateningly ill in 94) .. only once in my career have I "suggested" that termination of back to back salbutamol rx as the Patient was shaking violently a clear indication that the "liter" of salbutamol nebulised was "thereputic" and his heart rate was 148 bpm.

On to chbare .. he is relatively <gasp do I dare say that ?> new to this RRT gig and I can tell you from some bedside experience that attempting quantifying the paeds or youth 'level of distress" using a PEFR is a waste of time and effort (search the site for Ridrider911 comments) .. although to yank his chain and I did disagree but he was mostcorrect PEFR are useless with the peads population as there are no "predicted norms" although tending is a good idea, as is documented PEFR if one is discharging from ER.

I just wanted to emphasise a few points. For example, oxygen will not be all that helpful. In fact, in some cases, we may administer a mixture of 20-30% mixture Oxygen and 70-80% Helium while we try to decrease obstruction with other methods. Also, the absence of wheezing is not always this disastrous silent chest everybody assumes. Agreed. A person can present with relatively milld symptoms and no wheezing, only to have significant airflow obstruction. This may not even be appreciated until you assess the PEFR and even perform bedside spirometry and you note a significant ice-cream scoop on the flow/volume loop. Asthma is much more complicated and subtle than many assume.

Clarification: O2 is very helpful to prevent or treat hypoxia in the asthmatic as there can be a serious O2 debt, due incresed WOB, in my experiance in Kanukistan we seldom if never used Heliox for asthma, other than for post extubation stridor, in ER CPAP (visions CPAP) or Bi level support is the "go to these days, neb in line. Simply love the PB 840 on PS with good fitting mask.

My post was not necessarily related to the topic at hand. If somebody is having trouble with their asthma and I just happen to be a first aider? I will most likely call an ambulance, provide emotional support, obtain a history and transfer my findings to the EMS crew. All this craziness about giving this MDI or that MDI to a patient is not all that relevant as you have pretty much stated. Perhaps, it would apply in some rural situations or outlandish disaster scenarios, but for the most part, I'll wait for EMS.

Well gosh darn good thing your not in Canada .. you would be held to practice within your scope, especially under these circumstances, a first aider or not capacity, if you withheld or discouraged treatment with your extensive background in medicine, (the extreme leading to death) that you would be judged by a group of your peers now because there are extremely few (like 6 in Canada RRT / REMT-P) .. best hope I am not in the rouges gallery. J/K...

Yes I understand that fear of litigation is the driving factor in the USA ... pity really that legislation is so backward.

cheers

edit for smiley

Edited September 5, 2011 by tniuqs

[chbare]

I don't live in Canada and where I live, as John Q public, I am am essentially a first aider when not at work. Generally agree with the litigation issues, but I have to be real careful because respiratory and nursing are my only sources of livelihood and is what keeps me from being homeless, so I am not all that keen on doing things that may compromise this. We actually use Heliox with a fair amount of frequency over here. Agree on paediatric PEFR values; however, They are still useful for trending as you stated and can still give us information about how somebody is responding to therapy. Again, somebody can have relatively mild symptoms yet be experiencing significant airflow obstruction that can be treated. also agree that Oxygen may help with hyperaemia, hypoxia and oxygen debt, but will do nothing to resolve underlying airflow obstruction.

Edit: Delta to plural.

Edited September 5, 2011 by chbare

[crotchitymedic1986]

A little off topic, but chbare, I wish you could work at my shop. I can't tell you how many times, after ordering a neb, I hear, "Well, I didn't give it to him because he wasn't wheezing."

Really, Really ? So you are advocating giving a treatment based on your assessment skills when the equipment says you should not, and then you get upset when newbie morons who cant assess without equipment overrules your orders ? Seems like I read a similar thread where you argued the exact opposite just a few days ago. Why the flip-flop ?

In case you forgot, I am discussing the thread where I advocated giving D50 (1/2 amp) to an unconscious diabetic patient with a normal glucose reading.

Edited September 5, 2011 by crotchitymedic1986

[Asysin2leads]

I think we're viewing this from different angles. The question as I understood it was if a BLS level ambulance (EMR in Canada, EMT-B in the states) in a system that does not allow off the ambulance MDI's or Nebs who has responded to a 911 call. I'm talking one with full transport capabilities and somewhere in the range of a maximum of 45 minutes to an hour of a definitive care or at least an ALS intercept. I'm not talking about being on a aircraft, or a ferry, or if you're hiking or in some other similar circumstance. In these circumstances, anything can become the proper course of action. That guy who had to saw his own arm off to extricate himself from under the rock did the proper course of action in his situation, but I don't think anyone would argue that in day to day operations, a field amputation for a person with a simple pinned extremity is the proper course of action. And yes I'm aware that field amputations do occasionally occur, but again, they are exception, not the rule. In the normal course of day to day operations, you should not be administering pharmaceuticals not prescribed by a physician to the patient unless you have the appropriate knowledge of their indications, contraindications, actions, and a general understanding of pharmacology. You further complicate issues when you start using bystander medications. This has nothing to do with litigation, that's my view of good clinical practice.

In addition, the point that think is most important is that an asthmatic who is in danger of serious deterioration needs more than an MDI. I have seen far more situations where people spend time searching for an MDI as the definitive cure all for a serious asthmatic rather than calling 911, or in the case of a BLS crew, reaching for the BVM and initiating transport. I once brought an asthmatic out of a bradycardic PEA only using a BVM and an OPA. While I was doing this the family and bystanders were still trying to squirt an MDI into her mouth.

Lastly, where I worked, the department of anesthesiology had the heavy hitters for the difficult crash airway in the ER. They were the ones the residents didn't want to call while insisting they knew what they were doing. That's what I was getting at.

Edited September 5, 2011 by Asysin2leads