# "Asthma attack"



## Chris EMT J (May 22, 2022)

You are dispatched to a male in there 30s with CC of asthma attack. BLS called because they gave a neb that didn't improve his difficulty breathing and the eta was long. So the sample they took was weird on the notes. Symptoms/signs said SOB, hyperventilation, and uncontrolled leg shaking. No allergies. Medications were symbicort, albeterol, and Xanax. But only said history of asthma. Patient was obviously anxious so I tried to relax them while the medic was talking with the EMTs. Vitals HR 130 BP 130/85 O2 96% RR 35 BGL 110 temp 98f. Clear breath sounds on the pre neb and post neb note. Which I found interesting. The medic gave a med for anxiety which the patient said did nothing. En route vitals change to HR 80 BP 110/70 O2 97% RR 12. Thoughts? I am going with some anxiety and maybe something else that isn't obvious.


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## DesertMedic66 (May 22, 2022)

Sounds like the meds kicked in during transport…


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## NomadicMedic (May 22, 2022)

What did the capno waveform look like?


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## Chris EMT J (May 23, 2022)

DesertMedic66 said:


> Sounds like the meds kicked in during transport…


Exactly mine and the medics thoughts.


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## Chris EMT J (May 23, 2022)

NomadicMedic said:


> What did the capno waveform look like?


Completely normal


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## DrParasite (May 23, 2022)

ChrisEMTA said:


> Completely normal


So you have a normal capnography and clear lung sounds. both before and after neb... why did they give a neb treatment?

could that have made the anxiousness worse, as well as caused fast, irregular, pounding, or racing heartbeat or pulse, or shaking in the legs, arms, hands, or feet?


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## Chris EMT J (May 23, 2022)

DrParasite said:


> So you have a normal capnography and clear lung sounds. both before and after neb... why did they give a neb treatment?
> 
> could that have made the anxiousness worse, as well as caused fast, irregular, pounding, or racing heartbeat or pulse, or shaking in the legs, arms, hands, or feet?


They gave it because they trusted that the patient knew there asthma but I agree I wouldn't been convinced.


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## jgmedic (May 24, 2022)

ChrisEMTA said:


> They gave it because they trusted that the patient knew there asthma but I agree I wouldn't been convinced.


Exactly why BLS shouldn't be giving meds without more education


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## Chris EMT J (May 24, 2022)

jgmedic said:


> Exactly why BLS shouldn't be giving meds without more education


I really just think EMS providers just need recurrent training.


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## VentMonkey (May 24, 2022)

ChrisEMTA said:


> I really just think EMS providers just need recurrent training.


I believe it’s called continuing education.


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## MrBrown (May 25, 2022)

Your boy was not having an asthma attack and did not need salbutamol.  Asthma is classically characterised by bronchoconstriction with a long expiratory phase.  This is what produces the classic wheeeeeeze when you listen with a stethoscope.  The exception is patients who are so severely constricted they are moving so little air there is no wheeze audible.  The point of salbutamol (and salbutamol-like medicines) is to relax the bronchial smooth muscle.  I cannot remember the exact pathophysiology of why you get the smooth muscle contraction in asthma and don't care for it enough to look up, but you do.  Do not overlook the importance of taking all the pieces of the clinical situation into account.  For example, I would struggle to believe anybody with a SpO2 of 96% is having an asthma attack significant enough to require a bronchodilator. 

I accept very much some patients know their disease better than you, because, well, they do.  I do not see this as one of those times from what you describe.  Just because someone says "this feels like an asthma attack" is not an indication to administer salbutamol, or really, any medicine, without at least some objective confirmation.

I think the major learning point here for you is the importance of objective assessment and diagnosis and not being overly swayed by the patient.  I can think of at least several occasions where the attending ambulance personnel have been unduly swayed by a patient who calls for chest pain saying "I feel much better" into leaving them at home and whoopsie doodle they die sometime later of cardiac arrest or a ruptured AAA.

Oh, and why take a blood sugar on a patient complaining of SOB? Does dysglycaemia present with SOB? The answer is no.  So it is pointless.


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## DrParasite (May 25, 2022)

jgmedic said:


> Exactly why BLS shouldn't be giving meds without more education


ahem, those BLS providers shouldn't be giving meds... please don't lump all of us hose draggers and ambulance drivers into those two who didn't seem to know how to do their jobs.   Some of us know not to give meds when there are no indications to do so...

oh, and @ChrisEMTA , check out this website, as it might describe the patient's signs and symptoms





						Albuterol (Inhalation Route) Side Effects - Mayo Clinic
					






					www.mayoclinic.org


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## Chris EMT J (May 25, 2022)

MrBrown said:


> Your boy was not having an asthma attack and did not need salbutamol.  Asthma is classically characterised by bronchoconstriction with a long expiratory phase.  This is what produces the classic wheeeeeeze when you listen with a stethoscope.  The exception is patients who are so severely constricted they are moving so little air there is no wheeze audible.  The point of salbutamol (and salbutamol-like medicines) is to relax the bronchial smooth muscle.  I cannot remember the exact pathophysiology of why you get the smooth muscle contraction in asthma and don't care for it enough to look up, but you do.  Do not overlook the importance of taking all the pieces of the clinical situation into account.  For example, I would struggle to believe anybody with a SpO2 of 96% is having an asthma attack significant enough to require a bronchodilator.
> 
> I accept very much some patients know their disease better than you, because, well, they do.  I do not see this as one of those times from what you describe.  Just because someone says "this feels like an asthma attack" is not an indication to administer salbutamol, or really, any medicine, without at least some objective confirmation.
> 
> ...


BGL is a part of our routine vitals so its our protocol to get a BGL on everyone. Also as a person with asthma and a provider I don't think the O2 sat contributes to the administration of Albuterol. You can have symptomatic bronchial constriction with a normal O2 sat and it sounds reckless not to treat the bronchial constriction without a bronchial dialator.


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## Tigger (May 25, 2022)

MrBrown said:


> Oh, and why take a blood sugar on a patient complaining of SOB? Does dysglycaemia present with SOB? The answer is no.  So it is pointless.


I think hyperglycemia often presents to patients as a breathing problem but what do I know. If you feel there is a reason to check a BGL, do so. I’m not sure I would have here, but to say shortness of breath never needs a BGL is silly.


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## johnrsemt (Jun 8, 2022)

I used to check BGL with every IV, all that free blood everywhere, might as well make use of it for something, but our new IV catheters have a valve in them so they don't bleed everywhere anymore.

If the RR was faster I would say it was asthma that was well on the way to resp failure and the patient wasn't moving enough air any longer to wheeze;  but not fast enough:  I usually get in the high 70's to 80's when that happens.  Had a co-worker that refused to give me a breathing treatment, after my inhaler wasn't working all day, and I was dumb enough to call for a breathing treatment (trying to get out of transport) should have just driven in myself, but my wife wouldn't let me and she wouldn't drive me the hour to the hospital.  Medic refused the treatment, but took me to the hospital anyway:
ED doctor ordered an emergency breathing TX on me while I was still on the cot almost as soon as I was rolled into the ED, which was started before I got in a room.  RR 84, SPO2 76% on 6 L/m.  HR 120.  BP 120/70 (High for me).   I had 3 tx done in 2 hours (it took 1 full one before I started wheezing),  medic later told me that since I wasn't wheezing, he didn't think it could be asthma.


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## E tank (Jun 8, 2022)

MrBrown said:


> Oh, and why take a blood sugar on a patient complaining of SOB? Does dysglycaemia present with SOB? The answer is no.  So it is pointless.


Exactly...because no one ever presents with more than one problem at a time...ever. Like septic patients for example....sepsis...one problem....


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## Akulahawk (Jun 9, 2022)

With a *normal* capnography waveform, and a BGL of 110, I highly doubt the problem was asthma or diabetes related. That being said, one could easily have a SpO2 of 96% and yet need a bronchodilator not because of an oxygenation failure, but rather failure to properly ventilate. I've seen patients that have SpO2 levels in the mid to high 90's that were breathing around 40/min on room air, that weren't wheezing. I don't mess around with them. I'll check the patient's EtCO2 and if that's not completely normal, that patient's going on BiPAP and probably getting a breathing Tx through the BiPAP. With a normal EtCO2, and a normal BGL as it appears to be in this instance, an anxiolytic probably will do quite nicely.


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## Akulahawk (Jun 9, 2022)

MrBrown said:


> Oh, and why take a blood sugar on a patient complaining of SOB? *Does dysglycaemia present with SOB*? The answer is no. So it is pointless.


Actually, it can. In the past month or so, I've had quite a few such patients presenting with a chief complaint of SOB that ended up on an insulin drip because the underlying problem was Diabetic Ketoacidosis. So, no, it is not pointless to check a BGL on such patients if the opportunity presents itself. Only a handful of those patients suspected or knew their blood sugar level was elevated.


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## MrBrown (Jun 10, 2022)

Re BM sampling.  I accept dysglycaemia, particularly if severe, may present with abnormal breathing.  Objectively abnormal breathing is clinically different from the subjective feeling of shortness of breath.  Somebody who has a primary complaint of feeling subjectively short of breath with no clinical signs or symptoms when taken together paint a complete picture of somebody who could well have dysglycaemia probably doesn't have it.  So, in such a patient, like the example given here, I would not do a BM.  I accept it is an importantly missed investigation in some patients where it is often important to rule it in or out to treat a reversible cause for another problem, for example, patients with seizure or feeling generally unwell with a history of diabetes.  The analogy is someone who has foot pain and no symptoms consistent with myocardial ischemia, you wouldn't do a 12 lead ECG just because she also has DM and abnormal presentation of pain is not uncommon in somebody with DM-caused neuropathy so might be an odd presentation of STEMI.


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## Akulahawk (Jun 19, 2022)

MrBrown said:


> Re BM sampling.  I accept dysglycaemia, particularly if severe, may present with abnormal breathing.  Objectively abnormal breathing is clinically different from the subjective feeling of shortness of breath.  Somebody who has a primary complaint of feeling subjectively short of breath with no clinical signs or symptoms when taken together paint a complete picture of somebody who could well have dysglycaemia probably doesn't have it.  So, in such a patient, like the example given here, I would not do a BM.  I accept it is an importantly missed investigation in some patients where it is often important to rule it in or out to treat a reversible cause for another problem, for example, patients with seizure or feeling generally unwell with a history of diabetes.  The analogy is someone who has foot pain and no symptoms consistent with myocardial ischemia, you wouldn't do a 12 lead ECG just because she also has DM and abnormal presentation of pain is not uncommon in somebody with DM-caused neuropathy so might be an odd presentation of STEMI.


Do  not forget that in this particular instance, the OP gets a blood glucose measurement on all patient contacts as this is part of their standard vital signs gathering. This is why the OP provided a blood glucose level to us in the first place.

So, instead of quibbling about whether or not a blood glucose check is or isn't appropriate in a given set of patients, how about we remember that some places require a certain data set to be gathered on all patients. 

As I have stated before, I have had patients that present with shortness of breath along with tachypnea. When combined with a few additional questions, sometimes you end up suspecting there is a potential for a blood sugar problem so you measure the blood glucose. Most of the time, it's not an issue, sometimes, it is...


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## DrParasite (Jun 20, 2022)

Akulahawk said:


> Do  not forget that in this particular instance, the OP gets a blood glucose measurement on all patient contacts as this is part of their standard vital signs gathering. This is why the OP provided a blood glucose level to us in the first place.


I will also reiterate, that not getting a BGL results in a QA flag which may or may not result in issues with ones employer.

At a former job, we were supposed to get a BGL on everyone.  So if someone gets shot 3 times, and we took him to the hospital without a BGL, the on duty supervisor would provide us with a QA flag, which would require the author to submit a justification or reason why BGL was not obtained, all of whom are reviewed by our clinical coordinator.  Does anyone really think the BGL was a factor in why this person needed an ambulance?  no, but it's just easier to prevent the QA flag by getting a BGL on every patient.


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## NomadicMedic (Jun 23, 2022)

DrParasite said:


> I will also reiterate, that not getting a BGL results in a QA flag which may or may not result in issues with ones employer.
> 
> At a former job, we were supposed to get a BGL on everyone.  So if someone gets shot 3 times, and we took him to the hospital without a BGL, the on duty supervisor would provide us with a QA flag, which would require the author to submit a justification or reason why BGL was not obtained, all of whom are reviewed by our clinical coordinator.  Does anyone really think the BGL was a factor in why this person needed an ambulance?  no, but it's just easier to prevent the QA flag by getting a BGL on every patient.



That is ridiculous.


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## E tank (Jul 5, 2022)

NomadicMedic said:


> That is ridiculous.


Especially because the ER nurse is just going to get another one anyway. It's just that this way, the junk yard dogs looking for red meat won't be able to hang the 'one off' hypoglycemic gsw coming to their ER  on you...


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