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Sacred Cows Make the Best Hamburgers

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References and Additional Information

Sacred Cow #1: Lights and Sirens

Sacred Cow #2: MONA for Chest Pai

Sacred Cow #3: ACLS for Cardiac Arrest Care

Epinephrine

Dextrose

Sodium Bicarbonate

ACLS

Sacred Cow #4: ‘Normal’ F*cking Saline

 

Cite this article as: Scott Kostolni, EMT-P, "Sacred Cows Make the Best Hamburgers," from SickPatient.com, October 27, 2018, date accessed: November 21, 2018 http://sickpatient.com/burgers/

Key Points from an article published in Issue 2, Volume 22 (2018) of the National Association of EMS Physician’s Journal: Prehospital Emergency Care regarding the safety concerns of first responders on scene of an Opioid Overdose.  This article focuses on the specific risks and dangers poised by inadvertent absorption of “ultra-potent opioids” during patient care.

Boldface


  • Anecdotal reports of first responders affected by accidental opioid exposure during patient care have not been confirmed by any evidence based authority.
  • Vigilant scene assessment, universal precautions and standard PPE are sufficient to protect first responders on standard overdose scenes.

Introduction


  • CDC: Overdose deaths have reached epidemic proportions in the US.
    • Fentanyl related deaths are surpassing heroin deaths.
  • DEA has identified 15 synthetic opioids, 9 of which were reported for the first time in 2016.

Fentanyl Pharmacology


  • Primarily injected or ingested through mucous membranes.
  • Absorption through the skin requires pharmaceutical mechanism to achieve meaningful systematic levels.
  • Small studies of occupational exposure have shown clinically insignificant levels of fentanyl during prolonged exposure.
    • Absorption is through the hands and distal forearms.
  • Carfentanil and other synthetic opioid data is lacking.
  • Rapid absorption of crystallized or powdered fentanyl is unlikely
  • Copious water and soap should  be used to clean suspected contamination.
    • Ethanol based hand sanitizers may cause increased transdermal absorption.
  • Incidental mucous membrane exposure is unlikely.

Prehospital Exposure


  • Two types of exposures for first responders.
    • Healthcare response to a presumed overdose.
    • Confiscation of drugs evidence as part of law enforcement activities

Scene Assessment


  • Scene assessment, specifically for drug evidence and paraphernalia is recommended.
  • Powdered or packaged drugs should not be handled or disrupted by responders.
    • Do not attempt to identify the substance by touching or tasting the materials.
  • If unidentified powder is found providers should exit the scene as soon as it is reasonably safe.
    • Powder without evidence of disruption or airborne particles should not prevent access, treatment and removal of victim.
  • Universal precautions (gloves, long sleeves, pants, particulate masks) should be utilized.
  • There is no published data regarding first responder safety.

Personal protective Equipment


  • Single pair of nitrile gloves are recommended to prevent absorption of fentanyl if there is no evidence of visible powder.
    • Multiple pairs of gloves are not necessary
    • Gloves should be removed and properly disposed of after contact with potential opioids.
  • Masks are not necessary for routine overdose care.
    • Medical care is not expected to result in airborne drug particles.
    • If masks are used a standard surgical mask should be sufficient, an N-95 is also effective at providing a more complete seal.
  • Clothing should provide an effective barrier to direct skin contact.
    • If clothing is contaminated it should cleaned with a disinfectant wipe applied by a gloved hand.
    • Contaminated clothing should be changed and laundered at the first opportunity.
  • Full body and face cover may be required in environments with significant risk of airborne particles (manufacturing plants, weaponized deployment, known disturbance of powder).
    • Victims should be removed and treated in a safe location.
    • Hazardous Materials Teams may be needed.
  • Disturbing powder or other substances on scene are to be avoided.
  • Ethanol based sanitizers should be avoided. (See above)

Patient Care Considerations


  • Naloxone is still the appropriate therapy.
  • Primary risk is respiratory depression.
    • Assisted ventilation should be initiated at the earliest opportunity and should not be delayed for naloxone delivery or while awaiting a naloxone response.
  • Ventilation devices will not result in secondary provider toxicity.
    • Any visible powder should be removed prior to ventilation
  • Cardiac monitoring, pulse oximetry and nasal capnography should be applied when available.

Provider Exposure


  • Plans should be in place to manage potential responder exposure.
    • Providers should work in pairs, assistance should be requested when necessary.
  • Documenting of drugs and drug paraphernalia on scene is valuable but no first responder should handle any materials.
Cite this article as: Scott Kostolni, EMT-P, "Key Points: Scene Safety and Force Protection in the Era of Ultra-Potent Opioids," from SickPatient.com, April 24, 2018, date accessed: November 21, 2018 http://sickpatient.com/key-points-scene-safety-and-force-protection-in-the-era-of-ultra-potent-opioids/

References and Resources


  1. Michael J. Lynch, Joe Suyama & Francis X. Guyette (2017) Scene Safety and Force Protection in the Era of Ultra-Potent Opioids, Prehospital Emergency Care, 22:2, 157-162, DOI: 10.1080/10903127.2017.1367446

Sympathetic Crashing Acute Pulmonary Edema

Sympathetic Crashing Acute Pulmonary Edema (SCAPE) also known as Acute Pulmonary Edema, Flash Pulmonary Edema, or Acute Decompensated Heart Failure is a severe life-threatening emergency that requires quick and aggressive treatment to prevent respiratory collapse. When treated appropriately by prehospital providers this condition can be lessened or reversed and prevent an afflicted patient from becoming intubated, or admitted to the ICU.

Epidemiology


  • Demographics
    • Estimates are difficult to find.
    • Prevalence of 1-2% of western population rising with increasing age. of 2.2% for patients at 50 years, increasing to 8.4% at 75 years.
    • More likely found in women.
    • Concurrent medical history of Hypertension, Heart Attacks, and Coronary Artery Disease.
    • Typical Patient: Elderly woman with longstanding hypertension.
  • Risk Factors
    • Heart Attacks, Coronary Artery Disease, Bypass Grafts / Stents, Hypertension, Infections, Tachyarrhythmias, Drug Use, Congestive Heart Failure
  • Prescribed Medications
    • Betablockers, Diuretics, ACE Inhibitors

Pathophysiology


  • Acute injury such as a heart attack or prolonged stress of the heart muscle results in left ventricular dysfunction which causes hypotension and decreased renal perfusion.
  • Loss of arterial pressure activates the sympathetic nervous system to release catecholamines increasing heartrate and vasoconstriction, afterload increases.
  • Loss of blood flow to the kidneys activate the renin-angiotensin-aldosterone-system (RAAS) which worsens diastolic stiffening and increases diastolic pressures.
  • The effects of the catecholamines and RAAS causes intravascular fluid to permeate the pulmonary capillaries filling the interstitial and alveolar spaces.
  • TL;DR – Weak heart causes body to overcompensate and push fluid into the patient’s lungs.

Assessment Findings


  • Complaint: Severe respiratory distress with an acute onset (minutes to hours). Concurrent chest pain not uncommon, MIs are a common cause of SCAPE.
  • Mental Status: Restless, Agitated, Panicked. Tired, Weakness and Confusion is a sign of impending respiratory collapse.
  • Airway: Usually clear. Pink frothy sputum is possible and is a distinguishing factor for pulmonary edema.
  • Breathing: Rapid and labored. Bilateral rales is another distinguishing factor of pulmonary edema. Pulse Oximetry will be low.
  • Circulation: Tachycardic. Hypertensive (often 180 mmHg or greater). Skin may be diaphoretic and jugular vein distention may be found during assessment.
  • Diagnostic Testing
    • 12-Lead EKG: Check of Cardiac Injury or Ischemia and tachyarrhythmias.
    • Pulse Oximetry: 70s, 80s or lower.

Treatment


Fast aggressive treatment is needed to prevent patient collapse.

 

  • Non-Invasive Ventilation
    • Will provide oxygentation as well as stent open the affected alveoli for improved gas exchange.
    • BiPAP may show some advantages to CPAP but both are safe and effective.
    • Holding the mask on the patient’s face will make it more tolerable and allow rapid removal if intubation is necessary.
    • Start at 6 mmH2O of pressure and increase to 12-14 mmH2O until improvement.
  • High Dose Nitroglyercine
    • Targeted reduction of afterload to help restore correct pulmonary pressures and return fluid to the intravascular space.
    • High Dose Nitro is safe for patients suffering from SCAPE. Intravenous bolus doses of up to 2 mg have been used safely and effectively. In the unlikely event hypotension occurs it can be resolved with a normal saline bolus.
    • Dosage:
      • Sublingual Nitro Tab or Spray (0.4 mg)
        • Systolic Blood Pressure > 200 mmHg give Nitro SL x3 (1.2 mg) q 5 min
          Systolic Blood Pressure > 160 mmHg give Nitro SL x2 (0.8 mg) q 5 min
          Systolic Blood Pressure > 120 mmHg give Nitro SL x1 (0.4 mg) q 5 min
      • Titrate to relief and a target Systolic Blood Pressure of 140 mmHg
    • Intubation
      • May be required if respiratory failure occurs. First pass success is and preoxygenation will be difficult.
Cite this article as: Scott Kostolni, EMT-P, "Sympathetic Crashing Acute Pulmonary Edema," from SickPatient.com, February 3, 2018, date accessed: November 21, 2018 http://sickpatient.com/scape/

References and Resources


  1. Agrawal, Naman, et al. “Sympathetic crashing acute pulmonary edema.” Indian Journal of Critical Care Medicine , vol. 20, no. 12, 2016, p. 719. Health Reference Center Academic ,
  2. Anand Swaminathan, M. (2015). Acute Pulmonary Edema. [online] Core EM. Available at: https://coreem.net/core/ape/ [Accessed 4 Feb. 2018].
  3. Scott Weingart. EMCrit Podcast 1 – Sympathetic Crashing Acute Pulmonary Edema (SCAPE). EMCrit Blog. Published on April 25, 2009. Accessed on June 29th 2017. Available at [https://emcrit.org/emcrit/scape/ ]
  4. Clemency, B., Thompson, J., Tundo, G., & Lindstrom, H. (2013). Prehospital High-dose Sublingual Nitroglycerin Rarely Causes Hypotension. Prehospital and Disaster Medicine, 28(5), 477-481. doi:10.1017/S1049023X13008777
  5. Walenczak, D. (2017). Episode 18: Dry Land Drowning. [online] CritMedic. Available at: https://www.critmedic.com/podcasts/episode-18-dry-land-drowning/ [Accessed 4 Feb. 2018].

PCR: Heart Block

This is an example PCR narrative using the Pre-SOAPeD format. Read about Pre-SOAPeD and EMS Documentation here.

PRE-ARRIVAL:
Unit 292 responded emergent from headquarters for a reported Unconscious / Unresponsive at 123 Hogwartz Lane in the city of Outer Space with a full crew and without delay.

SUBJECTIVE:
On arrival, found a 64 year Male patient weighing 136 KG. Chief complaint of Unresponsive.

-History of Present Illness-
Wife at scene states she heard a loud bang and found her husband on the ground verbally responsive. She states patient had felt agitated earlier today but had no other complaints before incident.

-Histories-
Medical/Surgical History: Diabetes Type II, EMP / Emphysema, PNA – Pneumonia, Sleep Apnea, Coronary Artery Disease, Hypertension / HTN, Smoking Tobacco, CAT – Cataract, CABG / STENT / Bypass Graft, Personal history of antineoplastic chemotherapy, Cholecystitis.
Environmental Allergies: Bee venom allergy. Medication Allergies: Augmentin.
Current Medications: metoprolol succinate, Fenofibrate, irbesartan, Isosorbide, Lasix, Humalog, Levemir, Lyrica, NITRO Nitroglycerin, Omeprazole, oxcarbazepine, Pristiq, Vitamin D, Vitamin E.

OBJECTIVE:

-Initial Exam-
At 14:41, the patient was found. Initial assessment revealed the patient physically responsive and only able to make eye contact. Airway Patent, Lung sounds clear but diminished bilaterally, breathing pattern regular. Skin pale, cool diaphoretic, pulses weak, slow and irregular. GCS of 8 (Eye = 3, Verbal = 1, Motor= 4), Initial Vital signs, P – 32 II, R – 10.

-Secondary Exam-
Head to toe exam of patient revealed pupils regular round and reactive, HEENT CLR, negative jugular vein distention or tracheal deviation, abdomen distended non-rigid in all four quadrants, negative signs of trauma. Positive urinary incontinence noted.

-Lab Values-
Blood Glucose: 203; 3-Lead EKG showed complete heart block 30s-40s. SPO2 Initial 80% Room Air.

ASSESSMENT:
The field impression of the patient was [Cardiovascular] Cardiac Arrhythmia/Dysrhythmia.

PLAN:
Treatments were administered as follows:
14:42: Patient Assessment was performed successfully after 1 attempt.
14:42: Blood Glucose was performed successfully after 1 attempt.
14:43: Airway Opened was performed successfully after 1 attempt.
14:44: Oxygen 15 Liters Per Minute (LPM [gas]) NRB/PRB per Protocol (Standing Order). The patient’s response was Improved.
14:47: 3 Lead ECG Obtained was performed successfully after 1 attempt.
14:47: Pacing (External) was performed successfully after 1 attempt.
15:00: Medical Control Contacted was performed successfully after 1 attempt.
15:15: CPR – Manual was performed successfully after 1 attempt.
15:15: Bagged Ventilations (via Mask) was performed successfully after 1 attempt.
The patient was transported to Our Lady Of Holy Crap Hospital Emergent (Immediate Response).

-DELTA and HANDOFF-
Patient moved on stretcher, O2 administered, patient maintained airway and respiration on his own. Patient showed improvement with trans-cutaneous pacing (rate 60 bpm and 110 mA with mechanical capture) and was able to answer questions. Notification made to Medical Control resuscitation team requested.

Upon arrival at ED patient was moved to Cardiac Bed 1. Full report given to staff and in-hospital resuscitation begun immediately. EMS provider stayed and assisted transfer of pacing to hospital device when pulses were lost and CPR began in resuscitation bay. ROSC achieved shortly after and ED physician placed transvenous pacing device. Patient left in bed, with rails up, bed locked in staff presence.

Cite this article as: Scott Kostolni, EMT-P, "PCR: Heart Block," from SickPatient.com, November 3, 2017, date accessed: November 21, 2018 http://sickpatient.com/pcr-heart-block/

PCR: Penumonia

This is an example PCR narrative using the Pre-SOAPeD format. Read about Pre-SOAPeD and EMS Documentation here.

 

PRE-ARRIVAL:
Unit 292 responded emergent from headquarters with full crew and without delay for a reported Breathing Problem / Respiratory at 123 Hogwartz Lane in the city of Outer Space.

SUBJECTIVE:
-HPI-
On arrival, found a 61 year Male with a chief complaint of “I’m having trouble breathing,” as stated by patient. Secondary complaint(s) of Vomiting, Fever and Weakness.
Patient stated he awoke with above complaints this morning but recalled feeling normal last night before bed. Complaints worsened with movement, and patient felt best while lying in his bed. Patient describes respiratory distress as an inability to catch his breath and states he feels exactly like he has in the past when he’s contracted aspiration pneumonia. Patient had not tried any interventions before calling 911.

-Histories-
The patient’s medical history, medications and allergies are noted below.

-Review Of Systems-
GENERAL-Fever, chills, weakness;
RESPIRATORY-shortness of breath, dyspnea on exertion;
GU/GI-Vomiting, Nausea;

OBJECTIVE:
-Primary Exam-
Patient alert and oriented to person, place, time and event, airway patent lung sounds clear and equal bilaterally with the exception of ronchi in the upper left and even chest expansion, respiratory pattern rapid and labored, skin pale with positive signs of distal circulation. GCS of 15 (Eye = 4, Verbal = 5, Motor= 6).

-Secondary Exam-
Exam revealed pupils equal and reactive, abdomen soft, non-tender, non-distended in all four quadrants. Exam otherwise unremarkable.

-Lab Values-
Initial V/S of 172/80, P – 122 RR, R – 24. Initial SPO2 87% on Room Air. EKG showed Sinus Tachycardia 110-130s negative for STEMI.

ASSESSMENT:
The field impression of the patient was Pneumonia, unspecified.

PLAN:
Treatments were administered as follows:
07:15: Patient Assessment was performed successfully after 1 attempt.
07:17: Oxygen 12 Liters Per Minute (LPM [gas]) NRB/PRB per Protocol (Standing Order). The patient’s response was Improved.
07:31: 3 Lead ECG Obtained was performed successfully after 1 attempt.
07:33: 12-Lead ECG. Interpretation was Sinus Tachycardia 110-130, does not meet STEMI criteria. Lead: I, III, II, V1, V2, V3, V4, V5, V6, AVF, AVL, AVR.
07:33: 12 Lead ECG Obtained was performed successfully after 1 attempt.
07:35: IV Access – Extremity Vein20 gauge, was performed successfully after 1 attempt.
07:37: Ondansetron 4 Milligrams (mg) Intravenous (IV) per Protocol (Standing Order).
The patient’s response was Improved. The patient was transported to Our Lady of Holy Crap Hospital Non-Emergent.

DELTA:
Patients SPO2 rose to 96% and then 100% on NRB, respiration rate returned to normal and patient vocalized relief. Nausea subdued after ondansetron. IV lost en route removed and bandaged before arrival at ED.

-Hand Off-
Full report given to staff upon arrival. Patient transferred to bed 6 via pull sheet, left with bed locked, rails up in staff presence with all therapies continued.

Cite this article as: Scott Kostolni, EMT-P, "PCR: Penumonia," from SickPatient.com, November 3, 2017, date accessed: November 21, 2018 http://sickpatient.com/pcr-pneumonia/

Pre-SOAPeD Documentation

Importance of Documentation


  • Documentation is an important and often neglected part of patient care. Strong documentation protects both the patient and the EMS provider.
  • Documentation should be thorough and paint a complete picture of the patient, their emergency and the care provided.
  • The more information you can give to the physicians at the hospital the more time you save for your patient and the better care they receive.
  • Poor documentation has been associated with increased mortality in certain patients.
  • Goal: To write thorough enough documentation to prevent the need for in-person deposition for litigation.

Documentation Formats


  • There is different formats for documentation including CHART, Timeline Narrative, SBAR, and SOAP.
  • The Pre-SOAPeD format created by Joe Paczkowski on his blog EMT-Medical Student has become my preferred method for documentation.
  • It is thorough, straightforward and helps bridge the gap between pre-hospital care reports and the in-hospital charts and progress notes.

Pre-SOAPeD Reporting Checklist


  • Pre-arrival
    • Ambulance Unit Number
    • Emergent/Non-Emergent Response
    • Call Type
    • Location
    • Crew type
    • Delays
  • Subjective
    • Chief Complaint
      • Age/Sex of patient
      • Position of the patient when found.
    • History of Present Illness
      • Signs and Symptom
      • Onset, Provocation/Palliation, Quality, Radiation, Severity, Time, Interventions
    • Allergies/Medications
    • Medical/Surgical History
    • Family/Social History
    • Review of systems (As Applicable)
      • General
      • Neurological
      • Psychological
      • Head, Ears, Eyes, Nose, Throat (HEENT)
      • Cardiovascular
      • Respiratory
      • Abdomen
      • Gastrointestinal/Genitourinary
      • Musculoskeletal
      • Hair, Skin, Nails
  • Objective
    • Initial Assessment
      • Initial Vital Signs
      • Mental Status
      • Airway, Breathing, Circulation
    • Secondary Assessment (Body System As Applicable)
      • General
      • Neurological
      • HEENT
      • Cardiovascular
      • Respiratory
      • Gastrointestinal/Genitourinary
      • Musculoskeletal
      • Hair, Skin, Nails
      • Lab Values (SpO2, EKG, BGL, etc)
  • Assessment
    • Primary Impression
    • Additional items of your differential that you cannot rule out.
  • Plan
    • Treatments, interventions, dosages, equipment sizes
  • Delta (“change,” or response to treatment) and Hand-Off
    • Patient’s response to treatments
    • Vital Changes
    • Reassessments
    • Transfer of care
      • Nurses name
      • Bed patient moved to
      • Status of patient at transfer

See: Pre-SOAPeD Examples

Review of Systems


  • An inventory of the body systems obtained by identifying the absence or presence of various signs and symptoms.
  • With a problem-focused assessment, the review of systems should be related to the chief complaint and EMS Provider’s primary impression.

Review Of Systems Checklist

General: Fever, Chills, Malaise, Fatigue, Night Sweats, Weight Changes
Neuro: Seizures, Syncope, Loss of Sensation, Weakness, Paralysis, Loss of Coordination, Memory Issues, Muscle Twitches, Signs of Stroke
Psychological: Depression, Mood Changes, Difficulty Concentrating, Anxiety, Irritability, Sleep Disturbances, Fatigue During the Day, Suicidal and Homicidal Thoughts
HEENT: Headache, Dizziness, Loss of Consciousness, Blurred Vision, Light Sensitivity, Double Vision, Halo or Auras, Changes to Sense of Smell, Epistaxis, Postnasal Drip, Sinus Pain, Sore Throat, Bleeding, Dental Issues, Ulcers, Changes to Sense of Taste
Cardiovascular: Chest Pain, Edema, Palpitations, Tachycardia, Arrhythmias, Hypertension, Cardiac Medications,
Respiratory: Shortness of Breath, Wheezing, Dyspnea, Orthopnea, Cough, Sputum Production, Hemoptysis, Bronchitis, Tuberculosis, Pneumonia, Asthma, Respiratory Infections
GI/GU: Appetite, Heartburn, Nausea, Vomiting, Diarrhea, Constipation, Hematemesis, Changes in Stool. Flatulance, Jaundice, Dysuria, Increase Frequency or Urgency of Urination, Hematuria, Flank or Suprapubic Pain, Erectile Dysfunction, Fluid Discharge, Testicular Pain, Menstrual Regularity, Last Menstrual Period, Dysmemorrhea, Vaginal Discharge, Abnormal Bleeding, Pregnancies, Contraception Use.
Hair, Skin, Nails:
Rash, Itching, Hives, Sweating, Bruising, Bleeding. Changes to Hair Color, Texture, Abnormal Loss or Growth. Changes to Nail Color, Brittleness, Texture.

Cite this article as: Scott Kostolni, EMT-P, "Pre-SOAPeD Documentation," from SickPatient.com, November 2, 2017, date accessed: November 21, 2018 http://sickpatient.com/documentation/

Resources and References


  1. Featured Imaged by NEC Corporation of American under Creative Commons License.
  2. Dana J. Laudermilch, Melissa A. Schaffer, Avery B. Nathens, Matthew R. Rosegart, Lack of Emergency Medical Services Documentation Is Associated with Poor Patient Outcomes: A Validation of Audit Filters for Prehospital Trauma Care, In Journal of the American College of Surgeons, Volume 210, Issue 2, 2010, Pages 220-227, ISSN 1072-7515, https://doi.org/10.1016/j.jamcollsurg.2009.10.008. (http://www.sciencedirect.com/science/article/pic/s1072751509014902)
  3. Mulvehill, S., Schneider, G., Cullen, C. M., Roaten, S., Foster, B., & Porter, A. (2005). Template-guided versus undirected written medical documentation: a prospective, randomized trial in a family medicine residency clinic. The Journal of the American Board of Family Practice 18, no. 6 (2005): 464-469
  4. Paczkowski, J. (2011, January 20). EMS Documentation: Introducing Pre-SOAPeD. Retrieved November 2, 2017, from https://emtmedicalstudent.wordpress.com/2011/01/20/ems-documentation-introducing-pre-soaped/
  5. LeBlond, R.F., DeGowin, R. L., & Brown, D. D. (2009) Degowin’s diagnostic examination (9th ed.). New York: McGraw-Hill Medical.
  6. www.cms.gov. (December 2010). Evaluation and Management Services Guide. Updated August 2017. Accessed November 2, 2017, from https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/eval-mgmt-serv-guide-ICN006764.pdf

Asthma Algorithm

Asthma Algorithm @SickPatient.com

Related: Asthma

Cite this article as: Scott Kostolni, EMT-P, "Asthma Algorithm," from SickPatient.com, November 2, 2017, date accessed: November 21, 2018 http://sickpatient.com/asthma-algorithm/

Asthma

Image from NIAID.

Epidemiology


  • 24.6 Million people in US.
  • 7.8% of the population
  • Most prevalent in ages 5-19 yrs.
  • 3,600 deaths per year.

Pathophysiology


  • Reactive airway disease in which the smooth muscles lining the bronchi and bronchioles contract.
  • Attacks generally triggered by a substance (dust, pollen, smoke, exercise, cold) and which irritates the smooth muscle via an immune response.
  • The resulting bronchoconstriction, and excess mucous production makes air movement difficult causing air trapping and increased pressure inside the lungs.
  • Breathing becomes difficult and potentially life threatening.

Treatment


  • See: Asthma Algorithm
  • Treatment focuses on reversing the bronchospasm.
  • First Line Medications
    • Albuterol – Selective Beta-2 agonist which causes bronchiodilation. DOSE: 2.5mg to 5mg nebulized.
    • Ipratropium Bromide – Anticholinergic which induces bronchodilation and dries up secretions in the respiratory tract. DOSE: 0.5mg nebulized.
      • Usually given with albuterol for the first 2 or three doses and then one dose every 20 minutes after that as needed.
    • Dexamethasone DOSE: 12mg IV/IOIM OR Methylprednisolone DOSE: 125mg IV/IO/IM – Steroids which act as anti-inflammatory agents and mitigate the immune response.
      • Dexamethasone preferred for its quicker onset of action and non-hypertensive properties as compared to Methylprednisolone.
  • For Severe Presentations
    • Epinephrine 1:1,000 – Alpha and Beta Agonist causing bronchodilation and reduces inflammation in the airways. DOSE: 0.3-0.6mg IM.
    • Non-Invasive Ventilation – BiPAP or CPAP. DOSE: Low PEEP (3cm H2O) with stronger IPAP (8cm H2O) if available. Increases air movement and helps drive nebulized medications into the lower airways where they are needed.
      • BiPAP is greatly preferred but CPAP can be considered with nebulized medications. Watch patient for signs of exhaustion or respiratory failure.
    • Ketamine – Anesthetic with bronchodilatory properties. DOSE: 1.5mg/kg IV OR 5mg/kg IM.
      • Studies on this are varied but can be used in attempts to stave off respiratory failure and to facilitate the use of non-invasive ventilation.
      • Induction agent of choice for Intubating asthmatics.
    • Magnesium Sulfate – Electrolyte which may increase bronchodilation. DOSE: 2gm in 100cc NS over 10 min IV/IO.
      • Studies vary on this but the drug appears to be safe to use and may be beneficial in severe cases when nothing else has worked.
  • Intubation of the Asthmatic
    • Treatments should be given aggressively in hopes of staving off the need for intubation.
    • Indications: Respiratory fatigue/failure; cardiac arrest.
    • Tips: Maximize pre-oxygenation; use largest ET Tube possible; Do not ventilation aggressively watch for breath stacking.
    • Meds:
      • Ketamine 2mg/kg AND
      • Rocuronium 1.2mg/kg OR Succinylcholine 2mg/kg
Cite this article as: Scott Kostolni, EMT-P, "Asthma," from SickPatient.com, November 2, 2017, date accessed: November 21, 2018 http://sickpatient.com/asthma/

References and Resources


  1.  Asthma. (2017, June 07). Retrieved November 01, 2017, from https://www.cdc.gov/asthma/most_recent_data.htm
  2. /u/MedicMoment. (2017, September). Medic Moment Asthma/COPD • r/ems. Retrieved November 01, 2017, from https://www.reddit.com/r/ems/comments/71neji/medic_moment_asthmacopd/
  3. Laing, S., Fenwick, R., & Yates, J. (2017, September). The Resus Room Podcast: Asthma Roadside To Resus. Retrieved November 02, 2017, from http://theresusroom.co.uk/asthma
  4. Swaminathan, A., MD, MPH. (2015, September 30). Life-Threatening Asthma. Retrieved November 02, 2017, from https://coreem.net/core/life-threatening-asthma/
  5. Scott Weingart. EMCrit Podcast 15 – the Severe Asthmatic. EMCrit Blog. Published on December 8, 2009. Accessed on November 1st 2017. Available at [https://emcrit.org/emcrit/severe-asthmatic/ ].
  6. Rezaie, S. (2015, May 28). REBELCast: The Crashing Asthmatic. Retrieved November 02, 2017, from http://rebelem.com/rebelcast-crashing-asthmatic
  7. Featured Image: NIAID. (n.d.). Asthma Inhaler [Photograph found in Asthma]. Retrieved November 2, 2017, from https://www.flickr.com/photos/niaid/5950870440/in/album-72157627224678834/ (Originally photographed 2011, July 18)