Hi all. I am from South Africa so this senario would have gone a little different for me. For one thing in our country, well DNRs donot really exist and nore do living wills. So no fighting for me. It is the patients decition and not the daughters and well we now have implied consent. Who is to say that she does not want the trust fund. This patient can be treated. I have had this pateint more than once (really is an old age thing). The problem is patients donot read text books and make our lives easy. Vital signs often over lap between lung cardiac/ respiratory pathology. So is this a bronchospasm with air trapping or cardiac asthma?. mmmmm. I was always taught that which ever one you pick must be hit hard. I am moving toward LUNG pathology. What is the ambiant temperature there, also what season is it. Being male he is more likely too have a rapid progresion of a life threatening brochospasm. I also agree that pneumonia must always be concidered.
I would not have tubed this patient. I agree that a Sulbutmal neb is good but i say it should be combined with Ipatropium Bromide for the first dose (COAD/ COPD patients often responed better to the anticholernergic for relaxation of the bronchial smooh muscle). We donot use CPAP on the road here as other than intubated patients so I am not going to comment. On the iv access side of things. The patient has large Juguler veins. Why not try there. I find awake patient tolerate it well and you have large bore access if needed. It is quick. Mag sulph is a good Idea. I would maybe hold of on the solumedral though. I like fluid in any brochospasm who is dehydrated - small boluses. I probably woud not have waited on scene to long with this patient. Neb, monitors, load high semifowlers. IV access if posible and get going while waiting for the first neb is being finnished. Pull out the adreniline, intubation equipment and iv salbutamal and put them next to you - my good luck charm.This is only my 2cents worth. What monitor were you using there.
Stay safe all