Need your 0.02 worth on Asthma Pt

[zzyzx]

Moonbeam895,

Are you sure that the hypotension is not due to vagal stimulation? That would seem more likely, esp. with peds. Anyway, why would intubation have any effect on intrathoracic pressure?

[Asysin2leads]

Thanks for the feedback. To clarify: our Peds Intensivists recommend the fluid boluses as fast as you can push them...by hand before we intubate, AND as we are intubating. You're not just risking bottoming out the blood pressure if you don't do this, the patient will brady and code on you as the intrathoracic pressure changes with the procedure( as it sounds like happened with this case. ) We've seen it over and over with EMS bringing in pts to the PICU/ED, and it could go so much easier for the pt and the teams if they had this in their protocols.

Agreed! If they need to be intubated, push boluses and DO IT. We try hard not to if it can be avoided because these pts are doomed to weeks of trying to wean off the ventilator and sometimes never make it off again. Each time they are intubated their risk of dying on the vent is increased about 50%. So in critical care, we'll try many other things to keep from having to intubate That being said, sometimes what will be...will be.

We don't always treat with diesel, and I don't think that's what I said. A thousand pardons if that's how you perceived it.

"So if you can scoop and run, treat w/ diesel" ??? Was there something I missed? The problem with this stuff is that sometimes we get so bogged down in the details of the complications that we miss the obvious. While there may not be a clear indications of when to intubate an asthmatic, being unable to decide who needs to be intubated is unacceptable.

Intubation is the last resort, so I don't come to the decision lightly, but when I do, its because the person is going to die or suffer serious complications if they don't get air, and at that point, things like increased intrathoracic pressure really are not the most pressing concern.

You know, most people don't realize that one of the more common rhythms in severe hypoxia, especially in pediatrics, is bradycardia. A bradycardic pediatric should automatically be considered to have an airway or breathing compromise until proven otherwise. While adults will sometimes will go into a fibrillation rather than bradying out due to hypoxia, it is not uncommon for even an adult to go into a bradycardic PEA from severe, prolonged hypoxia. Personally I have had at least three bradycardic PEA arrests that regained a pulse shortly after being intubated.

So, I'm wondering, all of these arrests you've seen who are bottomed out in the BP and are bradycardic, do you think its possible its not because of a lack of a fluid bolus or because of vagal stimulation, but its because people waited too long to fix the emergent problem and save the patient's life?

If someone is gasping for breath, they are getting intubated. I'm not starting two wide bores on them, I'm not doing anything but prepping and tubing.

[moonbeam895]

[quote="Asysin2leads"So if you can scoop and run, treat w/ diesel" ??? Was there something I missed?

With all due respect, I think you must have missed my whole post, except for the last sentence. Ref: Before you intubate.....

We can agree to agree on this one. I think we're both saying the same thing, though we do have different ways of saying it. Bear with me.

If someone with status asthmaticus has a sat of less than 94% on 40% NRB, decreased or absent breath sounds despite the chest moving up and down, maximal accessory muscle use, and altered mental status/is obtunded, then, by all means....intubate. It sounds like the original poster's patient had all or most of the things that score a "2" on the asthma scale and he probably did need to be intubated.....AGREED. But, if a patient can speak a partial sentence, is moving air at all, and there is any way that he can have kitchen sink therapy...O2, non-invasive PPV, bronchodilators, corticosteroids, mag, terbutaline, etc and get to definitive care pretty quickly, intubation should be avoided if at all possible. Transport rapidly instead, after you've gotten the drugs started. (My comment on solumedrol was that, once you had decided to intubate the pt, it would come after the fluids and intubation, since you won't see immediate benefits from it like you will the fluids or the Mag.Yes, definitely give it. It works....just later.) The reason I advised to TWD is due to the terribly increased morbidity/mortality for these patients once they are intubated. They frequently die from pnuemonia or other complications and never make it back off the vent. We see this in the intensive care setting, whereas EMS providers don't always see the long term outcome (or lack of it) for their patients. I'm sure you have your pt's best interests at heart and want to take the best care of them that you can. I have the utmost respect for our medics and EMTs.

The original poster had a question about why her asthma patients kept coding after being intubated.

Specifically speaking about the asthma patient, they have probably been sick for hours or days before they call you. They are tachypneic, which contributes to dehydration from rapid and prolonged exhalation, and they probably haven't been drinking fluids well. Typically, these patients are already very hypovolemic. Add this to the fact that they aren't moving air well... they have air trapping, mucous plugging and bronchospasm. With the intubation procedure, intrathoracic pressure suddenly increases with the pressure from mechanical ventilation, which leads to decreased venous return and decreased cardiac output. Add that to a bronchospasm, and you're in alligators up to your elbows. This leads to a bradycardic patient (not from vagal stim), who may not recover from the event.

Bottom line: do the best for your pt. If you think this means intubation, so be it. It's your call. But, think about preload issues WHEN you intubate if you want your pt to make it to the hospital without CPR in progress.

My 0.02 for what it's worth.

Be safe.