CAE D- Emergency Care

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Author:
samatwell
ID:
96826
Filename:
CAE D- Emergency Care
Updated:
2011-08-11 21:44:42
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asthma educator
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asthma educator
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  1. 5 risk factors for death
    • History of asthma
    • Hospitalization / ED visits
    • Medication use
    • Co-morbidity factors
    • Other
  2. Risk: History of asthma
    • Prior intubation for asthma
    • Prior ICU for asthma
    • HX of severe exacerbations
  3. Risk: Hospitalization / ED visits
    • 2 or more hospitalizations in the past year
    • 3 or more ED visits in the past year
    • Hospitalization or ED visit in the last month
  4. Risk: Medication use
    • Currently using systemic steroids
    • Recently withdrawn from systemic steroids
    • More than 2 SABA B2 per month
  5. Risk: Co-morbidity factors
    • Allergic rhinitis and sinusitis
    • Obesity
    • Stress / depression
    • OSA
    • GE reflux
    • Allergic bronchopulmonary aspergillosis
  6. Risk: Other
    • Low socioeconomic status
    • Inner-city residence
    • Illegal drug use
    • Poor symptom / severity perception
    • Sensitivity to alternaria (mold)
    • Lack of a written asthma action plan
  7. Emergency tx at home
    PF 50-79%
    • MDI: 2 tx of 2-6 puff 20 minutes apart
    • HHN: 2 tx 20 minutes apart
    • Reassess PF - Good response > 80%
    • Contact MD for FU
    • Continue SABA 24-48 hrs, consider systemic steroids
  8. Emergency tx at home
    Incomplete Response
    • PF remains 50-79% and continue wheezing / dyspnea
    • Contact MD immediately
    • Continue SABA / add systemic steroids
  9. Emergency tx at home
    Poor Response
    • PF < 50% with marked wheezing / dyspnea
    • Repeat SABA immediately
    • Start oral systemic steroids immediately
    • If distress not relieved, ED or 911
  10. EMS tx of asthma
    • O2
    • Albulterol (MDI c spacer or HHN)
    • If no Albuterol available, SUB terbutalin or epinephrine
    • Up to 3 txs per hr, then 1 per hr
  11. ED visits often indicate:
    Inadequate asthma management or plan for exacerbation
  12. ED goal for tx asthma exacerbation
    • Correct hypoxemia
    • Reverse airflow obstruction
    • Reduce likelihood of recurrence
  13. What to assess in ED
    • Brief hx
    • Physical exam
    • Lung function (FEV1 or PEF)
  14. Assessment: RR
    • Mild: increased
    • Mod: increased
    • Severe: > 30 / min
  15. Assessment: HR
    • Mild: < 100
    • Mod: 100-120
    • Severe: > 120
  16. Assessment: Speach
    • Mild: sentences
    • Mod: phrases
    • Severe: words
  17. Assessment: Accessory muscle use
    • Mild: not typical
    • Mod: present
    • Severe: present
  18. Assessment: Breathlessness
    • Mild: when walking
    • Mod: when talking
    • Severe: at rest
  19. ED tx: 6 steps
    • 1. O2
    • 2. SpO2
    • 3. SABA
    • 4. Anticholinergics
    • 5. Steroids
    • 6. Repeat assessments
  20. ED tx: O2
    • to pt with significant hypoxemia
    • to pt with PEF or FEV1 < 40%
  21. ED tx: SpO2
    • tks > 90%
    • if pregnant, infant or heart disease, tks > 95%
  22. ED tx: SABA
    • Albuterol, Levalbuterol or Pirbuterol x 3, Q 20-30 min
    • MDI with spacer normal
    • For children or severe obstruction, use HHN
    • Repeat Lung Function 15-20 min post each tx
    • If FEV1/PEF < 25% and <10% response, monitor for respiratory failure
  23. ED tx: Anthicholinergics
    • For pt with sever exacerbation or resp failure
    • Ipratropium Bromide
    • Not recommended if pt is hospitalized
  24. ED tx: Steroids
    • For moderate to severe asthma exacerbation
    • For pt not responding to SABA
    • For pt admitted to the hospital
    • Enhances recovery / reduces recurrence
    • Onset: 4-6 hrs
    • At discharge, 5-10 day course or oral steroids
  25. ED tx: Reassessment
    • After 3 doses of SABA
    • Include: subj symp, phys ex, lung func, SpO2 and ABG
    • If still 40-69% PEF, continue ED tx
    • Consider adjunct therapy if < 40% of PEF
  26. ED tx: labs
    • If severe, start tx first!
    • ABG
    • CBC
    • Serum theophylline levels
    • Serum electrolytes
    • CXR
    • ECG
  27. ABG
    • Acute asthma: inc RR, dec PCO2
    • Normal PCO2 w inc RR = severe obstruction and increased risk of respiratory failure
  28. CBC
    • Consider if fever or purulent sputum
    • Corticosteroids commonly cause leukocytosis (>WBC)
  29. Serum theolphylline levels
    Therapeutic Range: 5-20 mcg/mL
  30. Serum electrolytes
    • If pt takes diuretic or has cardiovascular disease
    • SABA decreases potassium, magnesium and phosphate
  31. CXR
    Not routinely performed
  32. ECG
    • Recommended if > 50 years
    • Recommended if hx of heart disease
  33. 6 Adjunct Therapies
    • 1. IV magnesium sulfate
    • 2. Heliox
    • 3. IV B-agonist
    • 4. IV luekotrience receptor agonist
    • 5. Non-invasive PPV
    • 6. Mechanical ventilation
  34. IV magnesium sulfate
    • If life-threatening or severe > 1 hr after therapy
    • Adult dose: 2g
    • Children dose: 25-75 mg/kg up to 2g
    • Inhibits calcium channels, thus reduces release of acetylcholine to improve respiratory muscle function
  35. Heliox
    • If life-threatening or servere > 1 hr after therapy
    • Makes airflow laminar, reduces airway resistance
  36. IV B-agonist
    i.e. isoproterenol
  37. IV Leukotriene receptor agonist
    i.e. montelukast
  38. Noninvasive PPV
    5 - 7.5 cmH2O to reduce accessory muscle workload
  39. Mechanical ventilation
    Pemissive hypercapnia to reduce excessive lung distension
  40. Children / Infant Consideration
    • Infants rapidly regress
    • Dec SpO2 sign of severe airway obstruction
    • Hospitalize if SpO2 < 92% after 1 hr of tx
    • PCO2 by arterial or capillary
  41. Children / Infant Consideration after initial tx
    • RSV infection
    • Foreign body obstruction
    • BPD Bronchopulmonary Dysplasia
    • CF
  42. Do Not Use in exacerbation:
    • 1. Sub epinephrine or terbutaline
    • 2. Theophylline / aminophylline
    • 3. CPT
    • 4. Mucolytics
    • 5. Anxiolytic and hypnotic drugs
    • 6. Antibiotics ? Unless asthma assc with bact pneum
    • 7. Aggressive hydration
  43. Respiratory Failure Signs and Symptoms
    • 1. Decreased mental status
    • 2. Worsening fatigue
    • 3. PCO2 => 42
    • 4. Inability to speak
    • 5. Intercostal retractions
  44. Admission Considerations
    • 1. Response to ED tx
    • 2. Duration of symptoms
    • 3. Severity of symptoms
    • 4. Severity of airflow obstruction
    • 5. Course of prior exacerbations
    • 6. Access to medical care / medications
    • 7. Support system
    • 8. Phychiatric illness
  45. Discharge: PEF or FEV1
    = > 70% and symptoms are nominal
  46. Discharge: Medications
    • Written instructions
    • Wean to levels pt will be using at home
    • Monitor at these levels x 24 hours
    • Make sure they have enough to complete regimen
  47. Discharge: Provide
    • PF to 5yrs and older
    • Review of MDI technique and environment controls
    • Referral to asthma specialist
    • FU appt 1-4 wks after discharge
    • List of local asthma education programs

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