Need your 0.02 worth on Asthma Pt

[Laura Anne]

This is my second cardiac arrest post resp arrest via COPD(asthmatic) in the past month or so.....

52yr old male C/C resp distress. Found him tripoding against a desk at relatives home. Only had Albuterol with him. Took 10tx prior to EMS intervention and w/o relief. Pt's severely hypoxic and uncooperative due to this current condition.

PMHx asthma, cardiomyopathy, HTN.

I put him on high flow O2 immediately, flowed by another Albuterol. Needles to say, it wasn't working. Pulsox on high flow reading 73%, poor reading via cool/diaphoretic exts. Pt became combative, punched co-worker in face and could not sit still with O2 in place. We attempted to restrain him and place the mask back on his face, but he wouldn't sit still. I couldn't get an IV yet because he was fighting us. He was now doing the 'guppy mouth' breathing so I grabbed the BVM and went to nasally intubate him. He went into resp arrest, vagalled down into his 30's, then went into cardiac arrest. 8.0ETT, 14g Lt EJ, 1mg Epi and 1mg Atropine IVP and CPR. I never got him back.

No in-line nebs at this job.

No CPAP due to short transport times in city(approx <5mins, entire calls approx <15mins).

No Solu Medrol.....took it away for now.

No 1:1000 epi SQ due to peripheral circulation shut down.

This call from Pt contact to ER doors and care transferred to ER team was 12 minutes.

I felt I could have done more, but not sure what. Hands tied due to lack of meds/equipment. What could have been done differently? :?

[chbare]

Bad situation. When intubated, auto PEEP can be a lethal problem. Sometimes you have to exaggerate your expiratory time. I have even herd of people pushing on the chest wall in a critical auto PEEP pt to decrease the pressure. I am not sure if this was a problem with your patient. He was obviously severely decompensated and waited until his situation was dire prior to calling for help.

Take care,

chbare.

[VentMedic]

This guy also most likely had complications from his medical history of asthma, cardiomyopathy and HTN such as pulmonary hypertension. Also, how compliant he was and/or how far behind he had gotten himself before you saw him can be a factor. Rarely do you have a pure asthmatic especially in the middle-aged adult. All the other systems that have be affected by "life" and the maintenance meds for COPD will start to show their break downs.

CPAP would not have been a wise choice in this type of patient...profound hypoxia with combativeness and air-trapping.

Even with intubation, you would have had an airway but ventilating would have been difficult even with a bag. Bagging in a very high dose of albuterol neb (15 to 30 mg of 0.5%) might have helped via mask or tube if given the chance for a quieter moment. It is doubtful albuterol alone would have made a difference immediately. Even in cardiac arrest, the airways may not relax for ventilaton/oxygenation.

In the ER, heliox(70/30) via a Jackson-Reese system with extra O2 bled in if necessary and high dose albuterol (via mask until intubated) might be attempted. Then once on a vent with heliox and a lot of knobology to get the lungs to tolerate the machinery, hopefully with sedation he would settle. Unfortunately, neuromuscular blockers and solumedrol don't get along and can result in permanent paralysis. If pulmonary hypertension is also coming into play, nitric oxide or Flolan may have to be utilized somewhere down the road after the airways are open enough to receive these meds. If this pt made it to the ER, it might have taken days for him to open up and a couple weeks on a ventilator. If there was another disease process that brought about this episode, it would have to be resolved. This would not be an easy patient even with the all the technology and drugs available.

[AZCEP]

This is my second cardiac arrest post resp arrest via COPD(asthmatic) in the past month or so.....

So you are getting good at them then, eh :wink:

52yr old male C/C resp distress. Found him tripoding against a desk at relatives home. Only had Albuterol with him. Took 10tx prior to EMS intervention and w/o relief. Pt's severely hypoxic and uncooperative due to this current condition.

With the number of treatments he took, we should not expect great results from our SVN/MDI's either

I put him on high flow O2 immediately' date=' flowed by another Albuterol.[/quote']

A good thought, but it doesn't sound like he was moving enough air to be effective.

[scope2776]

Very difficult case... the kind of case you shouldn't blame yourself about... really unfortunate.

The whole time I was reading it, all I could think about was RSI. I know you may or may not have this wonderful (and scary) tool. Epi IV was the only thing that would have helped him at the decompensated point you arrived at. But b/c the pt was combative you couldn't get a line so you couldn't do any drugs IV including RSI....

You ended up giving Epi for the arrest anyway - a whole mg.

Very tough call...

[scope2776]

After trying the bronchodilators you have, you are left with adjunctive treatments like, maybe some magnesium. With the number of treatments that he tried prior your arrival, and the difficulty you had with the meds you tried, some magnesium may have helped.

Yes! Totally forgot! Mag would defiantly be something to try... toss up if it would have worked or not...

[mediccjh]

Laura,

First off, don't beat yourself up. From the posts I've read that you've posted here and in other places, you know what the hell you're doing.

1. Was this an asthma or a COPD pt? MgSO4 wouldn't do jack for the COPDer.

2. Sounds like he called way too late. You win some, you lose some.

3. History of cocaine or heroin use? That exacerbates asthma, to the point of intubation.

You did what you could, and did your best. People die anyway. As long as you did everything you could within the scope of your protocols, you have nothing to worry about.

[Medic26]

He was obviously severely decompensated and waited until his situation was dire prior to calling for help.

Once they get this bad there isn't much you can do but attempt to help with the tools you have.

[fiznat]

Really, really tough call. Asthma codes are one of the absolute worst-- I'm sorry you had to go through it.

I'm not understanding the bit prohibiting you from using the epinephrine, though. I know that there was probably reduced circulation to the peripheral, but certanly not enough reduction to contraindicate a med! You were still reading on the puse-ox... low, but there was a reading. With a patient this bad I feel like I would have tried the epi anyways. With so little air exchange the nebs arent really going to help so you've gotta do what you can...

Sedation/RSI would probably have been indicated here as well, but like others have said, mucus buildup would have made it tough to ventilate regardless of how much the patient was fighting. It might have helped you get that IV sooner, though.

Also possibly racemic or ET epi?

Just my opinion though. Thats a tough call and it sounds like you did as well as you possibly could with it.

[ERDoc]

Listening to the history I would be concerned for several other things. With the cardiac history I would think about pulm edema, pericardial effusion and a few other things. Reguardless of what the underlying problem was there was probably nothing you could do given how combative he was without being able to RSI