Rosen & Barkin's 5-Minute Emergency Medicine Consult (82 page)

• Oxygen and oxygen saturation monitoring
  
• Nebulized β-adrenergic agonist: Albuterol
  
• Intubate for respiratory failure or severe fatigue.
  
• IV fluids if evidence of dehydration
  
• Rapid transport and good communication with ED
  

• Maintain SaO
  ₂
  >90–95%.
  
• β-adrenergic nebulizer(s): Albuterol
  
• Intubate for respiratory failure.
  
• 20 mL/kg 0.9% NS bolus if evidence of dehydration.
  

• Assess patient for signs of potential respiratory failure:
  
  • Cyanosis
    
  • Severe anxiety or irritability
    
  • Lethargy, somnolence, fatigue
    
  • Persistent tachypnea
    
  • Poor air entry, ventilation
    
  • Severe retractions
    
• Monitor oxygenation; titrate oxygen saturation to SaO
  ₂
  >95% (sea level).
  
• β-adrenergic nebulizer: Albuterol:
  
  • Frequent or continuous for severe asthma
    
  • Levalbuterol may require less frequent dosing and may be associated with less side effects.
    
• Ipratropium bromide may be added as adjunct to β-adrenergic agonists. Most effective when combined with 1st 3 doses of β-adrenergic agent in moderate to severely ill children
  
• Steroid therapy:
  
  • Oral for moderate exacerbations in those able to take oral meds
    
  • IV for severe exacerbations or in those unable to take oral meds
    
  • 1 dose of dexamethasone may be equivalent to traditional steroids
    
• SC epinephrine or terbutaline for severe or refractory asthma (rarely used)
  
• Magnesium sulfate may be useful in severe disease following standard therapy.
  
• Intubate for respiratory failure:
  
  • Ketamine is a useful induction agent.
    
• 20 mL/kg of 0.9% NS bolus if evidence of dehydration
  
• Heliox (oxygen and helium) may be useful but studies are inconclusive
  

• Albuterol (0.5% solution or 5 mg/mL):
  
  • Nebulizer: 0.15 mg/kg per dose, up to 5 mg per dose, q15–30min PRN
    
  • Metered-dose inhaler (MDI) (with spacer) (90 μg/puff): 2 puffs q5–10min, max. 10 puffs
    
  • Also available for nebulizer as 0.083% solution or 2.5 mg/3 mL
    
• Dexamethasone 0.3 mg/kg/dose (max.: 16 mg)
  
• Epinephrine (1:1,000) (1 mg/mL): 0.01 mg/kg SC, up to 0.35 mL per dose, q20min for 3 doses
  
• Ipratropium bromide: Nebulizer (0.02% inhaled sol 500 μg/2.5 mL), 250–500 μg per dose q6h
  
• Ketamine (for intubation): 1–2 mg/kg IV as induction agent
  
• Levalbuterol (0.63 and 1.25 mg vials): q6–8h by nebulizer
  
• Magnesium sulfate: 25 mg/kg per dose IV over 20 min; max. 1.2–2 g per dose
  
• Methylprednisolone: 1–2 mg/kg per dose IV q6h; max. 125 mg per dose
  
• Prednisolone: 1–2 mg/kg per dose PO q12h (available as 15 mg/5 mL)
  
• Prednisone: 1–2 mg/kg per dose PO q6–12h; max. 80 mg per dose
  
• Terbutaline/ (available as 1 mg/1 mL) (0.01%): 0.01 mL/kg SC q15–20min up to 0.25 mL per dose, q20min for 2 doses
  

• Albuterol
  
• Steroids
  
• Ipratropium
  

• Epinephrine or terbutaline
  
• Magnesium sulfate
  

FOLLOW-UP

• Need to individualize based upon subjective and objective assessment
  
• Persistent respiratory difficulty:
  
  • Persistent wheezing
    
  • Increased respiratory rate/tachypnea
    
  • Retraction and use of accessory muscles
    
• SaO
  ₂
  <93% (sea level) on room air
  
• Peak expiratory flow rate (PEFR) <50–70% predicted levels
  
• Inability to tolerate oral medicines or liquids
  
• Prior ED visit in last 24 hr
  
• Comorbidity:
  
  • Congenital heart disease
    
  • Bronchopulmonary dysplasia
    
  • CF
    
  • Neuromuscular disease
    
• Concomitant illness:
  
  • Pneumonia or severe viral infection
    

• Severe respiratory distress
  
• SaO
  ₂
  <90% or PaO
  ₂
  <60 mm Hg on 40% oxygen
  
• PaCO
  ₂
  >40 mm Hg
  
• Significant complications:
  
  • Pneumothorax
    
  • Dysrhythmia
    

• Good response to therapy. Observe in ED 60 min after last treatment before discharging:
  
  • PEFR >70% predicted based on age/height
    
  • SaO
    ₂
    >93% on room air (sea level)
    
  • Respiratory rate normal
    
  • No retractions
    
  • Clear or minimal wheezing
    
  • No or minimal dyspnea
    
• Good follow-up and compliance. Reduce exposure to irritants (smoking) or allergens
  
• Discharge treatment:
  
  • Intensive β-adrenergic regimen for 3–5 days
    
  • Short course (3–5 days) of steroids (2 mg/kg/day) for those presenting with moderate symptoms with consideration of ongoing therapy using nebulized or MDI routes. Patients with moderate or severe exacerbations should have arrangements made for inhaled steroids over a 1–2 mo period such as fluticasone, budesonide, or beclomethasone
    
  • Follow-up appointment 24–72 hr
    
  • Instructions to return for shortness of breath refractory to home regimen
    
  • Long-term therapy should be considered for children with recurrent episodes, persistent symptoms, or activity limitations.
    

Primary care physician for maintenance therapy, often including nebulized or MDI steroid therapy and education about acute rescue management.

• Rapid treatment with continuous re-evaluation to detect any progression of disease is essential.
  
• When admitting patients, assure that β-adrenergic agent therapy is not interrupted.
  

• Krebs SE, Flood RG, Peter JR, et al. Evaluation of a high dose continuous albuterol protocol for treatment of pediatric asthma in the emergency department.
  Pediatr Emerg Care.
  2013;29:191–196.
  
• National Heart, Blood and Lung Institute; National Asthma Education and Prevention Program.
  Guidelines for the diagnosis and management of asthma
  . Bethesda, MD: NIH; 2007.
  
• Robinson PD, Van Asperen P. Asthma in childhood.
  Pediatr Clin North Am
  . 2009;56(1):191–226.
  
• Scarfone RJ, Friedlaender E. Corticosteroids in acute asthma: Past, present, and future.
  Pediatr Emerg Care
  . 2003;19(5):355–361.
  

See Also (Topic, Algorithm, Electronic Media Element)

• Bronchiolitis, Pediatric
  
• Pneumonia, Pediatric
  

CODES

• 493.00 Extrinsic asthma, unspecified
  
• 493.02 Extrinsic asthma with (acute) exacerbation
  
• 493.90 Asthma, unspecified type, without mention of status asthmaticus
  

BASICS

Absence of ventricular electrical activity

• An end-stage rhythm, sometimes degrading from:
  
  • Prolonged bradycardia
    
  • Prolonged ventricular fibrillation (VF)
    
  • Prolonged pulseless electrical activity
    
• Patient is extremely unlikely to survive when asystole occurs outside the hospital:
  
  • ∼40% will have return of spontaneous circulation and survive to hospital admission, but <15% survive to hospital discharge.
    
• Prognosis is similarly poor for those patients who develop asystole after countershock for ventricular tachycardia/VF; <10% survive to hospital discharge.
  
• Potentially reversible causes include:
  
  • Hypoxia
    
  • Hypovolemia (blood loss)
    
  • Acidosis
    
  • Hyperkalemia
    
  • Hypokalemia
    
  • Drug overdose
    
  • Hypothermia
    
  • Pulmonary embolism
    
  • Myocardial infarction
    
  • Tension pneumothorax
    
  • Cardiac tamponade
    

DIAGNOSIS