Ep 46 - Intro to EM: The patient with asthma

Introduction Welcome to the St. Emlyn's induction podcast recap, where we dive deep into the management of asthma in the emergency department. Asthma is a prevalent condition that emergency medical professionals encounter frequently. This blog post will provide a detailed step-by-step guide to managing patients presenting with asthma, including case presentation, assessment, treatment, and discharge planning. Whether you're a seasoned practitioner or new to emergency medicine, this guide aims to enhance your understanding and improve patient outcomes. Case Presentation: Recognizing Severe Asthma Imagine you're in the resuscitation room when you're alerted about an incoming patient. A 30-year-old female with a history of acute severe asthma is being brought in. She's a smoker, consuming 20 cigarettes a day, and has had a history of hospital admissions, including an ICU stay a few years ago. As she is wheeled in, you notice she is short of breath with audible wheezing. This initial presentation provides critical information for immediate action. First Steps: Rapid Assessment and Initial Management Upon the patient's arrival, it's crucial to make a rapid assessment. Conducting an ABC (Airway, Breathing, Circulation) assessment is essential to confirm the diagnosis and gauge the severity of the asthma attack. Given the patient's severe condition, it's vital to start treatment immediately while continuing your assessment. Immediate Actions High-Flow Oxygen: Administer high-flow oxygen to improve oxygen saturation levels. Nebulizers: Start with 5 mg of salbutamol and 500 mcg of ipratropium bromide. Don't hesitate to administer another dose if needed. Listen to the Chest: A quick auscultation of the chest can help confirm the presence of wheezes and rule out other conditions like tension pneumothorax. Understanding the Severity of Asthma Assessing the severity of asthma is critical to guiding further treatment. The British Thoracic Society provides guidelines that classify asthma into mild, moderate, acute severe, and life-threatening categories. Criteria for Severity Mild Asthma: Patients might experience mild dyspnea but can generally manage with minimal intervention. Moderate Asthma: Characterized by a peak flow more than 50% of predicted or best, moderate symptoms, and manageable at home with proper medication. Acute Severe Asthma: Marked by a peak flow below 50%, respiratory rate over 25, heart rate over 110, or an inability to complete sentences. Life-Threatening Asthma: Includes a peak flow less than 33%, low oxygen saturation below 92%, silent chest on auscultation, cyanosis, and signs of exhaustion. Continuous Management: Treating Severe Asthma In cases of severe or life-threatening asthma, continuous management and close monitoring are paramount. Back-to-Back Nebulizers Administering nebulizers continuously can help manage severe bronchoconstriction. Use salbutamol and ipratropium bromide back-to-back to provide relief. Steroid Administration Steroids play a crucial role in managing asthma by reducing inflammation. Administer oral steroids (1-2 mg/kg of prednisolone) or intravenous steroids if oral administration is not feasible. Intravenous Bronchodilators Consider intravenous bronchodilators like salbutamol if nebulized drugs are ineffective. Prepare IV salbutamol early to ensure it's available when needed. Magnesium Sulfate Magnesium sulfate can be considered in severe cases. Although recent studies suggest it might not significantly impact, it is relatively safe and may benefit a small subgroup of patients. Advanced Interventions: When Initial Treatments Fail If the patient's condition does not improve with initial treatments, advanced interventions may be necessary. Critical Care Consultation Engage with critical care colleagues early if the patient requires intensive care or ventilation. Ventilating an asthmatic patient is complex and requires experienced personnel. Additional Therapies Ketamine I