Acute Asthma.

[J306]

We had a similar scenario presented to us in class, (where patient is deteriorating despite 02, salbutamol and ipratropiumand) and had a similar discussion to whether we would give the nebs followed by epinephrine 0.5mg SQ.

My suggestion, like yours rock, was to give the nebs, then initiate CPAP. My instructor, however said that he considered it just splinting the symptoms instead of treating them, and that once you've initiated CPAP you have to continue that treatment at the hospital. He also mentioned that CPAP creates air-trapping in asthmatic patients which is why it would be a "last resort" treatment.

After discussing this case with my instructor for quite a while, we came to the consensus that if the patient is not responding to the nebs, 0.5mg epi is definitely the right treatment.

[chbare]

Just remember, the OP asked about respiratory arrest. In this setting, non-invasive ventilation would not be helpful.

[rock_shoes]

Just remember, the OP asked about respiratory arrest. In this setting, non-invasive ventilation would not be helpful.

True. It was more an exercise in possible ways to prevent getting to the point of respiratory arrest on my end.

If a patient is into respiratory arrest ventilate them as best you can and get invasive with the airway. Ketamine is a great choice for sedation in this case due to its bronchodilatory effects. Paralytics if you have them. Get more aggressive with the PEEP valve, permissive hypercapnea, side-stream or bag in your salbutamol/ipratropium bromide, 1:10000 epi (0.01mg/kg to a max of 0.1mg) IV, magnesium sulfate, corticosteroids. Be acutely aware of potential pneuomothoraces and prepare to decompress if need be. Seriously, throw the kitchen sink at them.

For some interesting reading on the topic of permissive hypercapnea:

http://www.ubccriticalcaremedicine.ca/academic/jc_article/COCC%202005%20Permissive%20Hypercapnea%20%28May-20-2010%29.pdf

[SympathomiMedic_123]

Hello!

Fantastic question, This is a patient you need to be very aggressive with in your treatments. Remember your systematic approach... Use your senses, Listen to their lungs, See their work of breathing, Feel their pulse are they anxious and tachycardic? If they are in FAILURE then we need to jump ahead of this 8-ball. You have confirmed asthma complications and your basic treatments are not working (Albuterol, Atrovent, Xopenex, etc,) and they are status asthmaticus- Now its time to be a Paramedic... Open up that drug box and break out the stethoscope... Status Asthmaticus.... Tight lung sounds, everything is inflamed and irritated and You will hear your stridors and your wheezes, note tripoding, accessory muscle useage, cyanosis, Sp02 in the dumps, etc. Its time to open them up. IV access is a must, I would start with adrenalin IV and Solu-medrol (Steroid) IV and watch and see, of course they are on 100% hi-flow right now as a given. If that doesnt work you can also try Magnesium Sulfate as it has great bronchiodilation and anti-inflammatory properties. However, if no success noted then its time to break out the Etomidate and the Succs cuz this patient is buying a tube. Airway control is a MUST. Just keep in mind treat your patient not your monitor, judge by their condition how aggressive your treatment will be.

Mark,

EMT-P

[systemet]

So, I am currently doing a case study and need to look at a medicine for the situation of respiratory arrest.secondary to asthma (when initial treatments such as salbutamol [b2 agonist] and ipratropium [choinergic antagonist] have had no effect)

As far as I have read adrenaline [epinephrine] is a good next step to take in this situation, but some sources have mentioned that the effect is little more than the other sympathomemetic and therefore the best option is a corticosteroid (we have hydrocortisone in NZ).

I think it's probably accurate that epinephrine's effect is "little more than sympathomimetic", but if you've been trying to deliver beta-agonist by nebuliser in someone you're having a difficult time ventilating, there may have been very poor absorption. If you go to an intravenous route, you will probably get more beta agonist into the bronchial smooth muscle.

I don't know if it matters whether it's epinephrine or ventolin. Epinephrine obviously comes with some pressor effects, that might be dose-limiting. Then again, it might help with venous return a little. IV ventolin has a reputation, deservedly or undeservedly, for causing cardiac irritability. I doubt there's any decent research comparing the two, but I haven't looked. Aminophylline used to be an option in some regions, but it's got a pretty narrow therapeutic index with lots of toxicity issues.

So just wondering, in a situation of respiratory arrest where IPPV is being given and we are on route to hospital - what is the most important thing to focus on, and is it perhaps worth considering intubation or even starting induction with ketamine and calling the helicopter?

If you have a status asthmaticus who's sick enough to have a respiratory arrest, you're likely going to be working a full arrest very soon. It's also going to be quite challenging to generate high enough airway pressures to ventilate them with a bag valve mask without an ETT, and even if you can, you're going to be diverting a lot of air into the stomach, and potentially setting yourself up for aspiration.

I agree with others that we should try to avoid intubating asthmatics, but I think once the patient has a respiratory arrest, it's time to drop the tube. Preferably a little before.

I think here:

* 0.1mg epinephrine 1:10,000 IVP

* laryngoscopy, with a lidospray at the ready, and a single quick attempt at intubation if you have a decent view.

* Repeated 0.1mg 1:10,000 IVP until you have an epi or ventolin drip ready.

* Ketamine if you need something to facilitate intubation, or if you bring the saturation up to the point that it's necessary.

Second line of attack

* 2g mag sulphate over 5 minutes. [This is a little fast, but the patient's pre-code].

* MDI ventolin / atrovent [probably not going to do much if the patient is very bronchoconstricted]

Third line

* Steroids. They'll help later, if there is a later.

I can look at any medicine at any skill level used in paramedicine anywhere that is appropriate for this situation, oh and pt has a chest infection - so I am thinking maybe steroids are contra-indicated?

Not unless it's fungal. I think you're ok to give the steroids here -- but if there's a suspected pneumonia / sepsis component, some additional fluid is in order, and other issues may be present.

Hope this helps.

[Blakes Username]

Awesome!

Thanks heaps for all the reply's, I hadn't even considered "I.V." Salbutamol, will go and check that out. CPAP is a cool idea, the study's appear to take a bit of looking for but I can see how it would be beneficial in an asthmatic so will look for some more info on that too - It would be interesting to see if the use of CPAP in combination w/ bronchodilators has been recorded.

[rock_shoes]

Awesome!

Thanks heaps for all the reply's, I hadn't even considered "I.V." Salbutamol, will go and check that out. CPAP is a cool idea, the study's appear to take a bit of looking for but I can see how it would be beneficial in an asthmatic so will look for some more info on that too - It would be interesting to see if the use of CPAP in combination w/ bronchodilators has been recorded.

http://www.ncbi.nlm.nih.gov/pubmed/21513584

I really don't like this particular CPAP device for reasons I won't get into here, but the concept is sound.

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[shortyemt]

Hi,

I hope my input will help you. I can speak to this issue from two sides, first being the side of being in EMS for 19 yrs and second and debaitablly the more important side , that being the side of the patient. I have had SEVER asthma for all my life some 50 years.

First a chest infection does not make Steriods contraindictated. Remember in most ped. cardiac arrest are secondary to respiratory arrest, that being said. RSI intudbation along with correct CPR /arrest protectol drugs would be my first response.The drugs I would recommend would be , local protectol RIs drugs, IV or IM epi, steriods, neb. albut., mag.,oxygen and closely monitor vitual signs . I would also member as the persson treating the patient you less often remembered jobs is to the one of the people the fight for the patients best welfare and never assume that someonelse will.

[BushyFromOz]

CPAP in respiratory arrest?

Reality is by the time you get to this stage you are well and truly behind the 8 ball, especially if your last line of drugs isn't already drawn up. the IMI adrenaline is best to go in when you start to see a loss of B/P. If they do respiratory arrest before you get them and they still have a cardiac output still give the adrenaline and ventilate them with chest thrusts and alow for a prolonged expiratory phase.

Corticosteroids do not have the time of onset you are after when they are dropping their bundle and should be lower on your priorities.

Either way the patient will declare themselves and you will start to get some air movment or they will lose output completely

This is a 4 person job being attended to by 2 people (or one if you driving). So delegating the right jobs in the right order will gte you out of the poo.

The window for RSI/IFS is so small after they lose consciousness that by the time you have your drugs drawn up and your gear out it will be a full cardio/resp arrest anyway so a cold tube then paralysis if you get a RSOC is more likely than a tube while they have apnoea but with output

The real practical answer would be get the IM adrenaline or preferably IV salbumatomol in earlier when they are still conscious, and avoid the resp arrest

IV salbutamol is the gas!

Beware the pneumothorax

Edited September 21, 2012 by BushyFromOz

[rock_shoes]

CPAP in respiratory arrest?

No. We were discussing options before it gets to that point.

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