Need your 0.02 worth on Asthma Pt

[bryan20w]

Laura,

From the sounds of it you did a great job for what you had to work with. Because you don't have room to tell us about all of your assessment, did you rule out a pneumo or a massive PE? Other than that like everyone else said he just waited too long to get help, like most asthmatics do!!!

[MSDeltaFlt]

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? :?

As far as inline nebs go, PM me your email and I'll send you to pics I've got for inline nebs that are cheap as all get out and very simple to set up. Vent knows what I'm talking about.

I've tried put them in this post, but it just won't work. That or I'm not holding my mouth right.

As far as handling the pt goes, it sounds like you were stuck on "B". He was too air hungry from hypoxia and his CO2 was through the roof so much that you weren't going to get him to anything compliant. The pt was behind the 8 ball before 911 was dialed. You did everything you could.

Holler back and I'll hook you up.

[Asysin2leads]

Laura, it sounds like you did all you could on this job.

The only change I would have made is that I wouldn't have spent time fighting with the NRB. In my opinion, given his state, the NRB and neb wasn't going to do much. The patient needed to be intubated. Until his airway was secure the only thing on my mind would have been sedation and intubation.

Perhaps someone can jump in here, but it is also my belief that when someone is at this point in COPD or Asthma, while 0.3 of epinephrine IM or nebulizers might help, they are really like using a garden hose on a house fire. My plan of attack would have been, sedation, intubation, neb down the tube, and 2 grams of Mag.

[moonbeam895]

Only thing I would add is a couple of rapid fluid boluses before you intubate. When you intubate an asthmatic, the sudden change in their intrathoracic pressure causes them to lose their preload and their BP will bottom out immediately. This is exactly why they code when you intubate them. Someone should be pushing fluids before and as you are placing the tube. The steroids won't kick in for about 4 hours, so I wouldn't bother with that until everything else is done. Aminophylline or terbutaline might help if you have those handy. We do everything we can to keep from having to intubate these pts, so if you can scoop and run, treat w/ diesel.

[snakemedic]

Please forgive me if this has already been mentioned but another "last ditch effort" might be to consider stop ventilations altogether after he arrests and some chest pressure to try to alleviate some of the air trapping, another option is blateral needle decompression, but in saying this, most of us have been there, hind sight is 20/20 and this is all academic after the fact. The best thing you can do is take all the great suggestions folks have offered and add it to that bag of tricks you have and draw on it next time. Sounds like you did great and you didn't fool around GOOD JOB!

[JPINFV]

Ok, I'm a little confused here. What good would bilateral needles do when the problem is air trapped inside the lungs and not air trapped inside the plural space?

[Asysin2leads]

Only thing I would add is a couple of rapid fluid boluses before you intubate. When you intubate an asthmatic, the sudden change in their intrathoracic pressure causes them to lose their preload and their BP will bottom out immediately. This is exactly why they code when you intubate them. Someone should be pushing fluids before and as you are placing the tube. The steroids won't kick in for about 4 hours, so I wouldn't bother with that until everything else is done. Aminophylline or terbutaline might help if you have those handy. We do everything we can to keep from having to intubate these pts, so if you can scoop and run, treat w/ diesel.

Treat with diesel. Nice. You know, I probably have one of the shortest distance to hospital times of any EMS provider in the world, and the only time I ever transport rather than attempt to intubate is if there is an extenuating factor.

When someone needs to be intubated they need to be intubate. End of story, and if they need it done, then do it sooner rather than later. If I think I can clear up and asthmatic without intubating, then by all means I go for it, its the right thing to do. But recognizing a patient who needs aggressive airway management and acting accordingly is one thing paramedics need to know like their own feet, and failure to act on it, for whatever reason, is not appropriate treatment. My saying is it might be five minutes to the hospital but it'll probably be 20 minutes to airway securement if we don't act.

I'd rather risk bottoming out a blood pressure than wait for a fluid bolus in a critical asthmatic. These theories of increased intrathoracic pressure are always good to keep in mind in case the patient codes (I'd say rather unlikely vs. the chances of coding because they are hypoxic) but the first and foremost thing should be sedate, intubate, move on. Oh, and the reason we give steroids right away is because they have a synergistic effect with the albuterol. Thats what my medical director told me and I'm sticking to it.

Every single person of the scoop and run crowd, I always want to take a plastic bag, put it over their head, and twist it real tight, then tell them it'll only be 5 minutes like this and its really for the best.

[ccmedoc]

Only thing I would add is a couple of rapid fluid boluses before you intubate. When you intubate an asthmatic, the sudden change in their intrathoracic pressure causes them to lose their preload and their BP will bottom out immediately. This is exactly why they code when you intubate them. Someone should be pushing fluids before and as you are placing the tube. The steroids won't kick in for about 4 hours, so I wouldn't bother with that until everything else is done. Aminophylline or terbutaline might help if you have those handy. We do everything we can to keep from having to intubate these pts, so if you can scoop and run, treat w/ diesel.

:bs: =P~

Treat with diesel. Nice. You know....

:evil4:

[stream:28c9994dbd]http://ccmedic.fileave.com/brutal.mp3 [/stream:28c9994dbd]

[moonbeam895]

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.

[moonbeam895]

Here is an excerpt from an article by Laura Ibsen, MD, which pretty much sums up what I was trying to say:

Intubation and Mechanical Ventilation

1. Indications: There are no widely agreed upon guidelines for when asthmatics require intubation. Intubation and mechanical ventilation are difficult and dangerous for the asthmatic, hence are avoided if at all possible. The difficulty arises as to when it is or is not possible.

Relative indications:

1. Apnea or “near apnea”

2. Diminished level of consciousness with inability to protect the airway.

3. Severe hypoxia despite supplemental O2 via 100% non-rebreather mask. Look also for evidence of impaired O2 delivery, i.e., presence or worsening of metabolic acidosis.

4. Consider at slightly earlier time if the patient needs to be transported to another facility. Intubation in the back of an ambulance is always suboptimal. This decision requires careful judgement.

2. Complications: Pneumothorax (high airway pressures needed), cardiovascular compromise or collapse (more deleterious cardiopulmonary interactions) aspiration during intubation, worsening bronchospasm (presence of foreign body in trachea)

3. Induction and intubation: The induction and intubation of the severe asthmatic during a severe exacerbation is particularly difficult to do safely. The patient usually must be considered to have a “full stomach,” is NOT a candidate for an “awake” intubation due to the intense bronchospasm that will occur if he/she is not adequately anesthetized, and will be difficult to bag-mask ventilate due to the high airway pressures required. In addition they are hypercapnic, usually hypoxic, usually dehydrated, and there are potentially detrimental cardiopulmonary interactions occurring (the blood pressure will fall with intubation). A rapid sequence induction is generally indicated.

Medications should include:

1. Lidocaine (to blunt the bronchospastic response to intubation) 1.5 mg/kg.

2. Atropine 0.015 mg/kg

3. Sedation-a combination of midazolam(0.05-0.1 mg/kg) and ketamine (0.5-1.5 mg/kg).

4. Paralytic-succinylcholine (premedicate with defasciculating dose of pancuronium 0.01 mg/kg) 1.5-2 mg/kg, or rocuronium 1.2 mg/kg. If using succinylcholine, remember to give a long acting neuromuscular blocker immediately after intubation is achieved (risk of pneumothorax with positive pressure ventilation).

5. Two functioning large bore IVs are essential. Start a fluid bolus as you are readying for intubation--additional preload will be neccessary for adequate cardiac output after the patient is intubated.