Need your 0.02 worth on Asthma Pt

[vs-eh?]

I have even herd of people pushing on the chest wall in a critical auto PEEP pt to decrease the pressure.

That is promoted here and often seen in "doctor's evaluation scenerios" in a pre-arrest/arrest asthma case. When I say "promoted", I mean to the extent that you may not pass if you do not do this maneuver.

[fiznat]

That is promoted here and often seen in "doctor's evaluation scenerios" in a pre-arrest/arrest asthma case. When I say "promoted", I mean to the extent that you may not pass if you do not do this maneuver.

Yikes. Does this procedure have a technical name? I'd like to do some reading on it.

[ALERT Medic]

The last one of these I had actually coded in the ED but after looking at his scenario and yours, I don't think there was anything that could have been done differently and it actually make a difference.

Some people just get too far into their problems before they call EMS and no matter how hard and fast we work, we just aren't able to keep up and do any real good. That's just my opinion though.

[sladey67]

Yikes. Does this procedure have a technical name? I'd like to do some reading on it.

Our protocol states ... "EXTERNAL CHEST COMPRESSIONS should be considered for asthmatics if condition is severe or extreme". We do this by placing our hands on lower portion of chest (bottom ribs) and gentle but firm posterior/medial compressions timed with pts expiratory effort. Often we might have to straddle the pt to do this!! but has been effective in many cases.

[Laura Anne]

To all who replied.....thank you!

Chbare,

I understand the concept behind the air trapping but figured if he wasn't too far along, it may have heled. You're right though. He was too far along and had absolutely no air movement complicated by his last bit of energy used up fighting us to have made any difference. After being intubated, my one EMT-B said it was really hard to bag and I informed him to bag small and quicker amounts, but not to attempt to over inflate.....a concept the other EMT-B who got clocked could not grasp(he is in his 3rd attempt through paramedic school...yeah...not the brightest lightbulb). Anyways, thank you for your response!

VentMedic,

High dose in line Albuterol....I guess if I had more time to be creative, I could have pulled out another neb set up and attempted to connect to the ETT/BVM ports? Other than that, is there a better set up? Thank you for your help....

AZCEP,

I am becoming a professional asthma killer! Grrrrr!!!!! :roll:

:wink:

Seriously though, I have heard of other meds being administered nasally, but Versed? Interesting, I'll look into that. And as far as Epi goes, I will have to think a little differently next time. It was one of those cases where everything happened so quickly that while I was setting up for one treatment, he presented in his next stage and didn't allow me to complete my first one.....how RUDE of him! ugh!! :roll: OHHH, Magnesium....yeah.......we don't carry that. Welcome to Montgomery County. Perhaps after these two past cases will make them consider it?? Thank you for your advice on this...food for thought, indeed!

Scope2776,

Once again, my county is a bit behind, but we're catching up...hence no RSI yet. As stated above, the time line of events inhibited my full thought process to ever properly evaluate the IM/SQ Epi. It did pass threw my mind, but I was more concerned with O2 admin and establishing/assisting with ventilation more than Epi....again hind site 20/20. I will be more aware of it for next time.....GOD FORBID.... :shock: Thank you for your response!!

mediccjh,

Thank you for your kind words. I will forever beat myself up on calls and push myself to obtain more knowledge every day so that I may perform better each time I am out there on the streets. Just the way I have always been...it's alllll good. :wink:

This guy was a well known 'frequent flier' and was well liked by everyone in the community, as well as the hospitals. Even though he was in the ER almost every other day or his asthma, he was always taken in and respectful to all who helped him, including the EMS teams in the local. This was the first time I ever saw him like this and it was unusual. This is when I knew the sh*t was going to hit the fan and just could not keep up with his decompsenatory state. No history of any drug abuse. Thank you for your kindness..... when are you coming to work with 'us' BTW???? :wink:

Medic26,

I appreciate your comment on the subject and will hopefully learn from the comments rom all on this event. Thanks!

fiznat,

As far as the Epi goes, I was assuming the peripheral shut down would have delayed and/or denoted any metabolic efforts at this time to help.....need to be more aware of it for next time. Racemic Epi would have been lovely, but we don't have it on board, although it was something I mentioned on scene. I wish we did carry it or the pedi asthmatics/croup cases we get. After my last "death by asthma" case, I asked one of the local ER doc's about it and he said it was worth a shot, but I was shot down at the ER via others due to it not being part of our protocols. Basically, I was told not to do it and to be a monkey medic which quite frankly pissed me off something FIERCE.....ER staff watched from the back doors of my truck while we coded him.....don't ask....bad situation all around.....hence my frustration with this ER from hell...........*rubbing ears and saying 'goose fava'*

OK, I am better....sorry for rant... :evil: Thank you for your help, though!! Your thoughts are always welcomed and well taken. I appreciate it very much! 8)

ERDoc,

RSI, as stated above would have been wonderful....cannot wait till we get it, although no line would make it a bit difficult. I am still pondering the Versed nasally.....I am going to have to seriously look into that!! Thank you for your comments!

vs-eh?,

Another point I will have to look into is the teachings of the chest wall compressions. Makes sense, so why the hell don't they teach it here?!?!!? Thank you for your response!

ALERTMedic,

ALl I can say is too little time, little too late......thank you anyways for your post!

sladey67,

'External Chest Compressions'.....can you send me or post the protocol for this, or perhaps something on it? I would greatly appreciate it! Thank you for your response on this topic! 8)

Basically.....give them Epi, try to sedate them if possible, and straddle them....to push on the chest! GAWD! :roll:

Thank you all again!!

[AZCEP]

Look for IN seizure control using an atomizer for the Versed. Might have been all you needed, or maybe not.

You carry an acceptable alternative to racemic epinephrine already. 1:1 000 in an SVN performs the same function as the commercially prepared solution. This patient likely would not have benefited much from it due to the lack of volume. If there was upper airway obstruction, perhaps, but not for strict asthma.

Use a little epi before they code, or a lot after they do. Luckily you weren't restricted, as some are, to using vasopressin after he arrested.

Live and learn.

[sladey67]

Laura Anne,

Our procedure for Expiratory Assistance - External Chest Compressions is:

Indication:

Asthmatic patients presenting with severe dyspnoea.

- Little or no air movement

- Chest will not deflate

- Extremely high inflation pressure (required).

Method:

1. Place both hands on lower lateral chest wall. If the patient is supine, face the patient and kneel astride the patient's hips.

2. Compress medially, synchronising with the patients expiratory effort and do not compress during inspiration.

3. With IPPV, compression commences with cessation of each positive pressure ventilation.

4. Compressions should be slow, rhythmic and sustained to help force air out.

Complications:

1. Fractured ribs

2. Hypotension

[AZCEP]

Aside from the manpower requirement, that sounds pretty reasonable.

Thanks for sharing that information. I've never heard of such a thing, and now I'm off to see if I can find more details on the procedure.

Always willing to make the envelope bigger.

[Laura Anne]

That's actually really interesting....thank you very much for sharing that.

When I think of manual or mechanical chest compressions, I think of those CPR vests that came out a few years back that were going to do the CPR for you. Does anyone know what I am talking about? It would be nice to see this type of vest made for this type of medical situation. A few problems with this is

1. making it to correlate with patients' irregular breathing pattern

2. hypotension

3. size factor

4. actual usage of the device due to low number of actual patients in need of such a thing

Mind wandering now.... :roll: OK, back to my late night ice cream and coffee....! 8)

[VentMedic]

More studies will have to be done before accepted to the mainstream in the US. There are studies currently being conducted to reduce hyperinflation quickly in the ED before the code situation including ventilators with an active exhalation instead of passive, heliox and vests.

This site has some potential studies that has been attempting to gain more interest in the area.

http://www.americanheart.org/downloadable/...8Nov04Final.pdf