Asthma

477 views

Published on

Published in: Health & Medicine
0 Comments
1 Like
Statistics
Notes
  • Be the first to comment

No Downloads
Views
Total views
477
On SlideShare
0
From Embeds
0
Number of Embeds
79
Actions
Shares
0
Downloads
7
Comments
0
Likes
1
Embeds 0
No embeds

No notes for slide

Asthma

  1. 1. Sometimes What Wheezes is Asthma Melissa Beckmann 10Jul 2013
  2. 2. What We Will Talk About  Treatment of Severe Asthma in ED  What works and What Does Not  Treatment of the Crashing Asthmatic What We Won‟t Talk About • Treatment of the Mild-Moderate Asthmatic
  3. 3. Today‟s Trivia OR OR
  4. 4. Asthma PSA
  5. 5. Risk Factors for Death in Asthma  Previous severe exacerbation (ICU/intubation)  2 or more hospitalizations for asthma in 1 year  3 or more ED for asthma in 1 year  Hospitalization/ED visit for asthma in last month  Using >2 MDI short acting β2 agonists in last month  Current or recent use steroids
  6. 6. Mainstays of Asthma Treatment
  7. 7. β2-agonists Camargo CA et al. Continuous versus intermittent beta-agonists for acute asthma. Cochrane Database Syst Rev. 2003;(4):C  N = 461 Adults and pediatric  Participants got either:  10-30mg albuterol over 2-4 hours OR q20 minute nebulizers, q30 minute nebulizers, or q1 hour nebulizers.  90% saw no benefit  10% decreased hospital admission rate CONTINUOUS IS BETTER
  8. 8. Ipratropium The nnt looked at 6 meta-analyses from 1999-2006  Ipratroprium added to beta 2 agonist therapy  N = 1500  Decrease in hospital admission by 9%  NNT = 11.5 (11.5 treated to prevent 1 admission)  3 nebules is the max for 6 hours IPRATROPIUM GOOD
  9. 9. Steroids Rowe BH et al. Early emergency department treatment of acute asthma with systemic corticosteroids. Cochrane Database Syst Rev. 2001;(1):CD002178  12 studies- Steroids given within 1 hour. Both pediatric (PO) and adult (IV/IM). Followed up between 3 and 21 days.  N = 863  NNT = 5  12.5% were helped by preventing hospital admission  10.0% were helped by preventing asthma relapse  9.1% were helped by preventing a later hospital admission GIVE STEROIDS
  10. 10. Mainstays in Treatment  β2-agonists  Hit „em hard, hit „em long  Anticholinergics  Especially effective in children  3 nebules max for 6 hours  Steroids  Give early but will take time to work
  11. 11. Trivia This resident competed in an Ironman and has the tattoo to prove it. Additionally, she has this license plate:
  12. 12. ANNA
  13. 13. IT‟S NOT WORKING, NOW WHAT?!?!?!
  14. 14. Magnesium BH et al. Magnesium sulfate for treating exacerbations of acute asthma in the emergency department. Cochrane Database Syst Rev. 2000;(2):CD001490.  N = 665 Both pediatric and adult  Most studies gave as bolus (1.2-2gm/20 min, or peds 25- 100mg/kg). 6/7 gave within 1st hour  67% no benefit  33.3% severe asthmatics prevented hospital admission  For severe NNT =2  100% non-severe asthmatics were neither harmed/helped GIVE MAGNESIUM EARLY
  15. 15. IV Epinephrine  Potent, Reduces Airway Resistance  α effect leads to vasoconstriction  1:10000 (crash cart epi)  0.25cc is a 25mcg push if crashing  2.5cc in 250mL NS (1mcg/mL sol‟n) run over 25 min (10mcg/min)
  16. 16. Non-invasive Positive Pressure Ventilation Non-invasive positive pressure ventilation for treatment of respiratory failure due to severe acute exacerbations of asthmaLim WJ, Mohammed Akram R, Carson KV, Mysore S, Labiszewski NA, Wedzicha JA, Rowe BH, Smith BJ. December 12, 2012  6 trials, N =206  Compared to usual medical care alone, NPPV reduced hospitalizations, increased the number of patients discharged from the emergency department, and improved respiratory rate and lung function measurements. The application of NPPV in patients with asthma, despite some promising preliminary results, still remains controversial. Further studies are needed to determine the role of NPPV in the management of severe acute asthma and especially in status asthmaticus.  Increases FRC, Decreases WOB USE NPPV
  17. 17. Trivia This resident is a former cheerleader, went to the best medical school in the country, hates public speaking, and is a bad ass rock climber.
  18. 18. ANNE
  19. 19. IT‟S STILL NOT WORKING, NOW WHAT?!?!?!
  20. 20. Intubation  18% mortality if intubated. Probably lower now that we have better vent settings  Death-asphyxia, tension ptx, reduced venous return  Diaphoretic/Decreased responsiveness
  21. 21. Intubate  Lidocaine (1.5mg/kg)  IV or inhaled  Reduces airway responsiveness  Ketamine (1-1.5mg/kg)  Weak bronchodilator  Can consider (0.5mg/kg) in agitated patient  Succ (1.5mg/kg) or Roc (1mg/kg)  Recommend giving ketamine/lido while sitting up and then laying down and pushing paralytics. Also recommend most experienced person place ET tube  Have the cric ready
  22. 22. Ventilator Settings  Barotrauma, Breathstaking, DEATH  Initial RR 6-8 breaths/min (DO NOT HYPERVENTILATE)  Small TV 5-7cc/kg  Small PEEP (0 or 2)  Large I:E ratio (1:5 up to 1:8)  Don‟t worry about CO2/acidosis  Keep plateau pressure under 30
  23. 23. Trivia This resident is president of AAEM/RSA, is the youngest 2nd year, is a country line dancing fiend, loves to shoot guns, has an amazing ability to NEVER be hungover.
  24. 24. MEG
  25. 25. CODE BLUE CRIT 5
  26. 26. Barotrauma, Breathstacking, Decreased Venous Return, DEATH  Fluid bolus 1-2L  d/c ET tube  If O2 sat is >88% manually press on chest for about 60 sec  Bilateral needle decompressions and chest tubes. DO NOT WAIT FOR X-RAY
  27. 27. Summary  Β2 agonists, ipratropium, steroids  Magnesium, IV epinephrine, NIPPV  Intubate using lidocaine, ketamine, paralytic  Low PEEP, low TV, long I:E ration, low RR, watch plateau pressure  If pt arrests think barotrauma: d/c ET tube, b/l needles/CT
  28. 28. Resources  The NNT  Cochrane Review  EM:RAP “The Crashing Asthmatic” April 2007  FOAM: http://emergencymedicineireland.com/2013/05/the- crashing-asthmatic/
  29. 29. Last Trivia This resident is the most socially awkward of the second years, often doesn‟t know what to do with her hands, also went to the best medical school in the country, and is thankful to finally made it through an intern year!
  30. 30. Melissa
  31. 31. Melissa
  32. 32. G-Induced Loss of Consciousness aka GLOC
  33. 33. How F-16 pilots die in the aircraft  Human Error  GLOC, Hypoxia, Spatial D  Jet Error  KIA
  34. 34. GLOC Graph
  35. 35. Prevention  Physical Fitness  Overall Health  G-Suit  Anti-G Strain Maneuver
  36. 36. G-suit
  37. 37. What GLOC looks like inside

×