REBELCast: The Crashing Asthmatic

Acute severe asthma, formerly called status asthmaticus, is defined as severe asthma unresponsive to repeated courses of beta-agonist therapy or subcutaneous epinephrine. It is a medical emergency that requires immediate recognition and treatment. Recently, Anand Swaminathan (Twitter: @EMSwami) gave a lecture to the residents at the University of Texas Health Science Center at San Antonio (UTHSCSA) February 2015. This post is a summary of that lecture on how to manage the crashing asthmatic.  Management of the Crashing Asthmatic Click here for Direct Download of Podcast Case: 45 year old male with known past medical history of asthma comes to ED via EMS with chief complaint of difficulty breathing. Vital Signs: BP 80/57     HR 146     RR 45     O2Sat 91% on room air EMS has already provided: Beta agonist therapy, Oxygen therapy, and IVF Summary of Heroic Medical Measures in the Crashing Asthmatic The initial management in the crashing asthmatic should be breathing, circulation, airway not airway, breathing circulation (i.e. "BCA" not "ABC").  We want to try and avoid intubation if we can.  Intubation of asthmatic patients was historically associated with increased morbidity/mortality. Pre-oxygenate your patient with high flow nasal cannula at 20 - 30 LPM . I have also written about this on REBEL EM -- Preoxygenation and Apneic Oxygenation Next consider using IM Epinephrine 0.3 - 0.5mg of 1:1000 . Severe asthmatics will have a hard time getting inhaled beta agonists into the small airways, but parenteral epinephrine will get into the circulation and get to where it needs to provide support. Non-Invasive Positive Pressure Ventilation (NIPPV) can help decrease work of breathing and help push beta agonist into the smaller airways . Corticosteroids main effect is to help reduce inflammation, but these effects won't be seen until 4 - 6 hours later.  It is important however to give corticosteroids early because this helps up regulate the beta receptors in the lungs at about an hour after giving the medication. Give IV magnesium sulfate for its bronchodilator effect, but don't just give 2g IV x1. Instead give 2g IV and repeat it upto 2 more times over an hour  . Give IVF at a dose of 30cc/kg because patients with acute asthma exacerbations because patients will have insensible losses.  Also if you are going to intubate patients with asthma, once they are intubated due to the positive pressure ventilation they will have a decrease in preload and IVF will help maximize preload. Sub-dissociative dose IV Ketamine (0.1 mg/kg followed by IV infusion of .5 mg/kg/hour for 3 hours) may be helpful to facilitate use of BiPAP in a hypoxic/combative patient . If you have gotten to this step you should start setting up for intubation at this point in case the patient continues to deteriorate. Delayed Sequence Intubation is a procedural sedation to help facilitate pre-oxygenation. . EMCrit -- Delayed Sequence Intubation (DSI) Intravenous epinephrine can be considered as well.  In hypotensive patients, it is possible that the IM epinephrine is just not circulating  . REMEMBER we want to use the 1:10,000 concentration here and even think about push dose epinephrine. EMCrit Podcast 6 - Push Dose Pressors Summary of Intubation in the Crashing Asthmatic Don't forget NO DESAT (Nasal Oxygen During Efforts Securing A Tube). This will buy you a longer apneic period while trying to intubate. Ketamine 1 - 2 mg/kg IV is the ideal induction agent du...