med 18

 

Treat underlying condition

*Note; you should initiate

treatment at any step if

patient is decompensating

.A. Figure 20-1 . Dyspnea diag nostic algorithm. ABCs, airway, breath ing, and circu lation; ABG, arterial blood gas;

CT, computed tomography; ECG, electrocardiogram.

TREATMENT

Establish IV access, cardiac monitor, and a pulse oximeter.

Think of monitors as a therapeutic intervention; being

aware of the patient's airway and gas exchange status is just

as important as intervening.

Supplemental 02 can come in multiple forms. Nasal cannula can accommodate 2-6 L/min of 0 2 comfortably. This

can increase Fi02 by 2-4% for each liter increase. A nomebreather mask (NBM) can and should go up to 15 L/min of

flow; any less leads to drawing back environmental air

through the mask, defeating the purpose. NBM can s upply up

to 60-70% Fi02 at 15 L/min (Figure 20-2). Bag-valve-mask

(BVM) provides 90-100% of Fi02 with 15 L/min of flow.

Proper 2-handed technique is highly recommended with

BMV use when there is an assistant available. Endotracheal

intubation is performed if respiratory arrest is imminent.

DISPOSITION

� Admission

Patients who are intubated, unstable, or have the potential

to become unstable should be admitted to the intensive

care unit. Patients who were initially unstable but improved

after therapy may be observed on a t elemetry unit. .A. Figure 20-2. Patient with nonrebreather mask.

CHAPTER 20

� Discharge

Patients who are stable with improvement in symptoms,

an identified nonemergent condition, and good medical

follow-up may be discharged.

SUGGESTED READING

Sarko J, Stapzynski S. Respiratory distress. In: Tintinalli JE,

Stapczynski JS, Ma OJ, Cline DM, Cydulka RK, Meckler GD.

Tintinalli's Emergency Medicine: A Comprehensive Study Guide.

7th ed. New York, NY: McGraw-Hill, 20 11, pp. 465--473.

Asthma

Matthew C. Tews, DO

Key Points

• Patients with severe asthma exacerbations may have

such severe restriction of airflow that they do not exhibit

wheezing on examination.

• Beta-2 agonists are the mainstay of treatment for acute

asthma exacerbations.

• Corticosteroids should be given to patients who do not

respond initially to beta-2 agonists and in those with

moderate to severe exacerbations.

INTRODUCTION

Asthma is a chronic disorder of the airways that is associated

with inflammation, bronchial hyperreactivity, and intermittent airflow obstruction. The most common chronic disease

in childhood, it is also common in the adult population.

Presentations of acute asthma account for more than 2 million emergency department (ED) visits annually. The causes

are multifactorial, but the pathophysiology is characterized

by the release of inflammatory cell mediators that lead to

airway smooth muscle constriction, pulmonary vasculature

leakage, and mucous gland secretion.

Asthma is characterized by progressive shortness of

breath, variable airflow obstruction, and wheezing. Symptoms fluctuate over time, and patients with worsening

symptoms due to a trigger are considered to have an "exacerbation" and require prompt treatment to reverse the

airflow obstruction.