So your patient's dead secondary to asthma, eh?

[vs-eh?]

So you have a patient that is in cardiac arrest presumably secondary to acute asthma exaserbation...or unresponsive same deal.

Probably in a PEA right? Differentials down likely due to hypoxia and watch for that pneumo...

So what do WE do now? Simple, we push on the chest...

That's right folks, I don't know how many of you do this in your services, but our physicians are now advocating constant chest presure (around the costal margin/diaphragm pushing in and up) for 30-60 secs to ensure a full exhalation prior to intubation/PPV. It makes sense though if ya think about it. I'm not going to go into the whole in depth patho of it (which you should know anyway) but bronchconstriction = prolonged expiration time = increased risk for air trapping/alvelor rupture/barotrauma = increased risk for pneumo = increased intrathoracic pressure = decreased venous return = compounding problems...

So ya, push on that chest for a bit until expiration/washout is complete before you bag or tube that person. And modify your vent strategy too of course...

Might save ya on those bilat. chest needles...

Comments?

[Beagle189]

Haven't heard of that. But you're right it does make sense. Now I gotta go talk to my Medical caontrol Doc.

[Lithium]

So is this similar to those alternate methods of CPR as previously recommended in ACLS? Such as 'interposed abdominal compression CPR' or 'active compression-decompression CPR'?

Sounds like the same idea to me ... just remember to watch your I:E times when venting ...

peace

[Ridryder 911]

Main point ! Asthma is a constriction/retention disease, not an obstruction...

R/r 911

[vs-eh?]

So is this similar to those alternate methods of CPR as previously recommended in ACLS? Such as 'interposed abdominal compression CPR' or 'active compression-decompression CPR'?

My understanding is that it is constant firm pressure around the costal/diaphragm margin up and in for 30-60 secs. It is done once, unless I assume there is evidence of continued air trapping/increased intrathoracic pressure/pneumo (I've never done it). I'm not familiar with "alternate CPR methods", but this isn't continuous compressions, nor is it done over the sternum, etc...

So no one has anymore comments? Is this just standard practice procedure prior to intubation/PPV for an asthmatic? Meh, I tried for something interesting anyway...

[TechMedic05]

Is this just standard practice procedure prior to intubation/PPV for an asthmatic? Meh, I tried for something interesting anyway...

I was always a fan of not putting a patient into arrest. COPD and Asthmatics, especially intubated, obviously require a longer expiratory phase in ventilation. If their body is producing a 5-7 second expiratory phase, like with pursed lip breathing, we should probably adapt similar numbers, if not longer when intubated. These patients are now getting 100% oxygen with pressure. A lot better than 21% oxygen without pressure. People look at me weird when I ask them to ventilate at 8 a minute.

Anyone have any idea of end tidal CO2 monitoring in a non-intubated patient would be helpful in determining a need for a longer expiratory phase in ventilation? I haven't been able to find a good description of etco2 monitoring in the non-intubated patient.

[Lithium]

I still say Ontario needs to catch up with the times and give us better vents, preferably with CPAP or atleast BiPAP and better PEEP control.

And VS, I'm disappointed ... are you not undertaking ACP training? You should know those ACLS provider manuals inside and out!

peace

[kevkei]

Sure BiPap and PEEP, but not in an arrest. That's where you'll really run into trouble. We've been hearing about doing this around here for a while although it's not in protocols or standard of care.

Another little trick in a known or suspected asthmatic arrest is dropping some epi down the tube once they are intubated, even with IV access. It works great for direct Beta II stimulation.

[AZCEP]

Good time to use your brain to think through the problem.

Vasopressin would probably not be too helpful, so it's out. The associated PEA will likely be slow, so Atropine would be considered, but Epi would be a better choice. The ventilations need a 1:2-3 inspiration/expiration time. Even timing the compressions/ventilations "might" be a reasonable thought.

In the most recent guidlines from AHA, there is a whole section on asthmatic cardiac arrest. Guess what, their recommendation is to prevent them from arresting in the first place. Who knew? Prevent the arrest, better survivability. :roll:

[TechMedic05]

Guess what, their recommendation is to prevent them from arresting in the first place. Who knew? Prevent the arrest, better survivability.

Wow! Foolproof EMS! We now need to follow through out parts. heh. #-o