The Critical Care track of the Society for Emergency Medicine in Singapore Annual Scientific Meeting 2014. For more information and conference videos, go to singem.blogspot.sg

1. Doc, I can’t take a deep breath!
Managing Life Threatening Asthma in the ED
Dr Ang Shiang-Hu
Consultant Emergency Physician
A&E Department
CGH

2. No disclosures

3. Scope
• Case study
• Pathophysiology
• ED management
• DSI
• Adrenaline

4. 60 year old female
• History of bronchial asthma, type 2 DM
• Apparently well before bedtime
• Sudden onset shortness of breath while
asleep

5. 60 year old female
• Paramedics noted bilateral wheezing
• SpO2 at scene 82% on room air
• Started nebs 2:2
• Driven with oxygen tank
• Enroute became drowsy and ? seizure like
activity

6. On arrival
• Patient was obtunded
• Struggling to breathe
• Abnormal belly movement
• Silent chest

7. On arrival
• T : 36.5
• HR : 116
• RR : 28
• BP : 168/99
• Cap BSL : 17.3
• SpO2 <50%

8. Recognize the condition
Pathophysiology of Life Threatening
Asthma

9. Features of life threatening asthma
Lugogo et al. Resp Care. 2008

10. 2 phenotypes
Gradual onset (80-85%)
• onset of days to weeks prior
to presentation
• moderate-to-severe airflow
obstruction
• airway-wall edema, mucus-
gland hypertrophy, and
thick secretions
• slow to respond to
treatment.
Sudden onset (15-20%)
• develops over minutes to
hours
• acute bronchospasm
• neutrophilic bronchitis
• faster therapeutic response
• shorter hospital stay
Picado. Eur Resp J. 1996Status asthmaticus
Asphyxic asthma
Acute Fulminant Asthma

11. Inhaled therapy will not work
There is hardly any airflow
Only ~10% of nebulized drug will
reach the bronchioles
Lewis et al. Br J Dis Chest 1985

12. Intubate this patient right away?
Half of all life-threatening complications
occur at or around the time of intubation in
these patients
Stanley et al. 2008

13. Intubate this patient right away?
A large portion of the morbidity and mortality in
these patients may be related to the mechanical
ventilation itself rather than the disease process
Darioli et al. 1984

14. 1. Continuous nebulized albuterol Use oxygen for nebulization not room air
8 liters per minute
Nebulizer will need to be refilled every 10-15 min
Dose is not important, keep making smoke
2. Nebulized ipratropium bromide 500 mcg, added to albuterol q20 min x 3, then q1h
3. Methylprednisolone 125 mg (1.5 mg/kg) IV Alternative: Dexamethasone 20 mg IM or IV
4. Magnesium sulfate 2 g (50 mg/kg, max 2 g) IV Give over 20 minutes
5. Nebulized epinephrine 0.5 mL of 2.25% racemic epi in 3 mL NS or 5 mL of standard 1:1000 L-epinephrine (1 mg in 1 mL)
Consider the differential
CHF
Pneumothorax
ACS
Arrhythmia
Pulmonary embolism
Airway obstruction /
Foreign body
Pericardial tamponade
1. Epinephrine 0.5 mg (.01 mg/kg, max 0.5 mg) IM Proper concentration of epi for IM injection is 1:1000 (1 mg in 1 mL), so 0.5 mg = 0.5 mL
May repeat q10 min, or start IV drip at 5 mcg/min and titrate to effect
Instant epi drip: 1 amp crash cart epi (1 mg in 10 mL) in 1 liter NS, start at 2 drops/sec, titrate up
Alternative to epi: Terbutaline 10 mcg/kg IV bolus over 10 min, then titrate from 0.4 mcg/kg/minute
2. Fluid bolus 20 cc/kg normal saline
3. Diagnostics: Chest X-ray, CBC, chemistry, venous blood gas, HCG, ECG if concern for non-sinus rhythm or cardiac ischemia
Agitated Patient
Management of Life-Threatening Asthma
in the Emergency Department
IF NO IMPROVEMENT
IF NO IMPROVEMENT
Able to Tolerate
NIV? YESNO
Ketamine
1.5 mg/kg IV over 30 seconds,
then 1 mg/kg/hour
Titrate drip to effect
If no IV: 5 mg/kg IM
Non-Invasive Ventilation
Inspiratory support / IPAP / PS: 8 cm H20
Expiratory support / EPAP / PEEP: 3 cm H20
Continue nebulizer treatments through NIV
IF WORSENING IF WORSENING
Step%One
Step%Two
Step%Three
IF WORSENING
Cooperative Patient
Non-Invasive Ventilation
Inspiratory support / IPAP / PS: 8 cm H20
Expiratory support / EPAP / PEEP: 3 cm H20
Continue nebulizer treatments through NIV
Ketamine
1.5 mg/kg IV over 30 seconds,
then 1 mg/kg/hour
Titrate drip to effect
If no IV: 5 mg/kg IM
IF WORSENING
Indications
Progressive fatigue / respiratory failure
Progressive deterioration of mental status
Cardiac arrest
Vent Management
Goal is plateau pressure < 30 cm H20
If Pplat too high, decrease rate, then tidal volume
Continue nebulized albuterol
Paralyze if needed, deep sedation/analgesia preferred
External chest compression to assist exhalation
Can accept saturation as low as mid 80s (goal ≥ 90%)
Can accept high pCO2 for several hours (goal pH > 7.15)
Aggressive airway suctioning
Frequent electrolyte checks, watch for hypokalemia
Consider inhalational anesthetic, heliox
Technique
Maximize preoxygenation
Optimize for first pass success
Induce while patient is upright
Use largest ETT possible
Be mindful of tendency to bag-mask
ventilate too aggressively; this
leads to breath stacking
RSI Meds
Ketamine 2 mg/kg +
Rocuronium 1.2 mg/kg or
Succinylcholine 2 mg/kg
Initial Vent Settings
Assist control / Volume control
Respiratory rate 8 breaths/min
Tidal volume 7 mL/kg IBW
PEEP 2 cm H20
Inspiratory flow: 90 lpm (or I:E 1:5)
FiO2 100%
If Patient Crashes on Vent
DISCONNECT VENTILATOR
External chest compression to assist exhalation
Bag mask ventilation - do not overventilate
Verify that ETT not displaced / clogged / kinked
Bilateral thorocostomy
Bolus fluid, epinephrine
Consider ECMO/bypass
Intubation%and%Ventilation%of%the%Asthmatic
AVOID INTUBATION
IF POSSIBLE
R. Strayer / P. Andrus / R. Arntfield / Mount Sinai School of Medicine / 8.11.2012
Plateau pressure is measured by
using the inspiratory pause function
and noting airway pressure during the
inspiratory hold
Strayer et al. Mt Sinai Sch of Medicine 2012

15. Rescue therapy
Delayed Sequence Intubation (DSI)
Parenteral rescue

16. Delayed sequence intubation
A new paradigm in airway
management

17. Weingart. J Emerg Med. 2011
doi:10.1016/j.jemermed.2010.02.014
Techniques
and Procedures
PREOXYGENATION, REOXYGENATION, AND DELAYED SEQUENCE INTUBATION
IN THE EMERGENCY DEPARTMENT
Scott D. Weingart, MD
Division of Emergency Critical Care, Department of Emergency Medicine, Mount Sinai School of Medicine, New York, New York
Corresponding Address: Scott D. Weingart, MD, Division of Emergency Critical Care, Department of Emergency Medicine, Mount Sinai
School of Medicine, 7901 Broadway, Elmhurst, NY 11373
e Abstract—Background: The goal of preoxygenation is to
provide us with a safe buffer of time before desaturation
during Emergency Department intubation. For many intu-
bations, the application of an oxygen mask is sufficient to
provide us with ample time to safely intubate our patients.
However, some patients are unable to achieve adequate
saturations by conventional means and are at high risk for
immediate desaturation during apnea and laryngoscopy.
For these patients, more advanced methods to achieve pre-
oxygenation and prevent desaturation are vital. Discussion:
We will review the physiology of hypoxemia and the means
ways. However, in a subset of patients, these techniques
will lead to inadequate preoxygenation and fail to pre-
vent desaturation. To safely intubate this group, an un-
derstanding of the physiology of oxygenation is essen-
tial to allow for optimal intubating conditions. This
knowledge can then be applied at the bedside in the
care of high-risk patients. The goal of this work is to
translate the tenets of physiology and the most recent
literature to allow the safest possible intubation of
critically ill patients.
Printed in the USA. All rights reserved
0736-4679/$–see front matter

18. A new paradigm
• Breaks down traditional approach to RSI
• Goal directed
• Focus on oxygenation as a goal
• High risk patients

19. A new paradigm
• NIV for pre-oxygenation
• Ventilator in place of BVM
• Apneic oxygenation
• Delay intubation till ready

20. DSI is…
• Carefully selected drugs
• Prepare the patient for pre-ox
• Support ventilation
• Treat underlying pathology and shock
• Paralyze and intubate, or stand down

21. Rescue medication #1
ADRENALINE

22. Adrenaline has a bad rep
It causes the shakes
It causes
dysrhythmias
It
causes heart attacks

23. Anaphylaxis literature
• Most of the adverse events in adrenaline use
comes from over-dosage
• Only five reported cases of AMI occurred in
the setting of therapeutic adrenaline dosing
Brener et al 2007
Shaver et al 2006
Shef et al 1993
Ferry et al 1986
Rubio et al 1999

24. Anaphylaxis literature
• Most of the adverse events in adrenaline use
comes from over-dosage
• Only five reported cases of AMI occurred in
the setting of therapeutic adrenaline dosing
• Young, ages 29-55
• ST elevation MIs
• Normal coronaries
• Coronary vasospasm

25. Cydulka et al. Ann Emerg Med 1987

26. How to dose adrenaline?
1:1000 adrenaline is
for DEAD people

27. How to dose adrenaline?
• IM or SC - 0.3mg (1:1000)
• Push dose (pressor) - 10 mcg boluses IV
• “Dirty epi drip” - 0.5mg (1:1000) in 500 ml
saline bag
• Infusion 1-10 mcg/min
http://academiclifeinem.com/dirtyepi/

28. Rescue medication #2
Ketamine

29. Clinical
Communicat ions: Adult s
INTRAVENOUS KETAMINE IN A DISSOCIATING DOSE AS A TEMPORIZING
MEASURE TO AVOID MECHANICAL VENTILATION IN ADULT PATIENT WITH
SEVERE ASTHMA EXACERBATION
Gil Z. Shlamovitz, MD*† and Tracy Hawthorne, MHS, PA-C*
*Department of Emergency Medicine, Windham Community Memorial Hospital, Willimantic, Connecticut and †Department of
Emergency Medicine, University of Connecticut Medical School, Farmington, Connecticut
Corresponding Address: Gil Shlamovitz, MD, Department of Emergency Medicine, Windham Hospital, 112 Mansfield Ave, Willimantic,
CT 06226; e-mail address: gilshla@yahoo.com
e Abstract—Background: Patients experiencing severe
asthma exacerbations occasionally deteriorate to respira-
tory failure requiring endotracheal intubation and mechan-
ical ventilation. Mechanical ventilation in this setting ex-
poses the patients to substantial iatrogenic risk and should
be avoided if at all possible. Objectives: To describe the use
of intravenous ketamine in acute asthma exacerbation.
Case Report: We present a case of severe asthma exacer-
CASE REPORT
A 28-year-old Hispanic woman presented to our Emer-
gency Department complaining of 8 h of progressively
increased wheezing and shortness of breath. The symp-
toms started after exposure to dust and paint fumes at her
home and did not respond to multiple albuterol treat-
ments using a metered dose inhaler. The patient reported
J Emerg Med. 2011

30. How to dose ketamine
Analgesic dose: 0.1 to 0.3 mg/kg
Dissociative dose: at least 1 mg/kg

31. Other adjuncts
Steroids
Mg SO4

32. Back to the case
• Took off the nebs
• Pre-oxygenate
• Intranasal O2
plus
• Put on non-rebreather mask
• Prepare intubating equipment

33. Initiate rescue meds
• IV adrenaline 10mcg at 2-3 minute intervals
for the 1st 10-15 minutes
• Followed by IV adrenaline 10 mcg/min x 1
hour
• IV ketamine 10mg at 10-15 minute intervals x
3 times
• Fluids, Hydrocortisone, MgSO4 on the other IV

34. Initiate rescue meds
• Good response after 10-15 minutes with
noticeably improved chest wall movement
and air entry
• Started continuous nebs x 3 cycles, SpO2
maintaining well with supplemental oxygen

35. After an hour and half in the ED
• Patient is awake, able to obey commands
• Good vitals: HR 90 BP 90/60
• Mild end expiratory wheeze
• Admitted to general ward
• Discharged well on Day 3

36. Another patient last month…

37. Summary : In near fatal asthma,
rescue your patients with…
Delayed Sequence Intubation (DSI)
Parenteral rescue

38. The END
Questions?
shiang_hu_ang@cgh.com.sg
@abciximac #sems2014
singem.blogpost.sg (Emergence Phenomena)