8 y/o Severe brochospasm scenario

[mc400]

Hey fella's just wanted to run a scenario I faced yesterday.

Dispatch info: 8 year old Female. Resp distress since last night, several albuterol treatments with no relief.

U/A Pt sitting on a couch surrounded by family members.
Pt in tripod position with obvious distress and working hard to breathe.
Pt on albuterol SVN supplied by room air nebulizer.
Wheezes only heard through stethoscope, 32 resp/min lungs sound coarse and very tight. Pt appears very tired and family states she has had 5-6 treatments throughout the night and it is now 1000hrs.

We followed protocol which for us is only combivent svn at 6-8lpm. There was no response or change at all in presentation.
We can patch for Mag 50mg/Kg in 50cc's over 20 minutes.
No standing order for Epi IM- but usual dose is .005-.01mg/kg IM, repeat in 10-20 minutes if no response.

Vitals
117/71
131 S/R sinus tach on monitor with no ectopy
32 labored resps with wheezes throughout, unable to say more than 1 word at a time.
94% Sa02
Cap refill delayed +3 seconds
Cool and clammy with cold extremities.
End tidal not available on our monitor.

1st problem-Rescue Ambulance coming from 4th due area about 15-17 minutes away.-No way to fix this.
2nd problem-Patient becomes frantic when attempting to establish IV so it is withheld initially. Attempted to fix by calming and reasurring pt and trying to remove family members from the area to calm her down. IV was established as soon as pt was moved to the ambulance and seperated from all of her family.
3rd problem-Unable to contact Base Hospital initially for orders for IM epi. Epi was given and when we finally contacted base Dr agreed with epi decision and said to repeat dose if needed and to hold off on mag.

What are some of the things that you guys would have done for this patient, what our your protocols for Pediatric resp distress/brochospasm?

 

[abckidsmom]

This sounds like a sick little kid. She's on the edge of respiratory failure, and I would not be surprised to see a kid presenting like this crash and crash hard within minutes.

I'd keep her on a continuous neb, give her epi, and hang the mag. If the doctor wanted me to hold off on the mag, I'd convince him that was not a good idea. You used all the right words typing this up, but if the online medical control doctor heard those and still wanted you to hold off on the mag, I'd probably take her to a different hospital.

Edit: With the all-night respiratory distress, I'd probably give her a bolus of fluid, too. She's probably dry.

 

[Shishkabob]

Epi, asap, by either IV or IM/SQ, whatever is quickest.

Try some inline Albuterol/atrovent forced in with CPAP / BVM if you have the ability.



All else fails, they just bought themselves a tube as they are closing in on, if not already at, failure.

 

[vquintessence]

Well it sounds like you treated with the pts best interests and to the best of your abilities. Her tachypnea, restricted air movement, poor spO2 (presumably on the neb?) and overall work of breathing certainly meet the criteria.

From my uncomfortable armchair, I would like the consideration of solu medrol and fluids.

 

[Shishkabob]

Solu-medrol is much too slow acting for what's currently needing to be fixed. Potentially nice after we get her breathing again, but Epi first and foremost.

 

[vquintessence]

Solu-medrol is much too slow acting for what's currently needing to be fixed. Potentially nice after we get her breathing again, but Epi first and foremost.

Clearly, but the key is synergy. He already gave the O2, duoneb, epi and was denied mag. Steroids certainly are within this childs future.

 

[reaper]

Have you ever used it on a completely shut down asthma pt?

It does act rather quickly in these cases and if is available, should be used sooner, then later.

 

[abckidsmom]

Have you ever used it on a completely shut down asthma pt?

It does act rather quickly in these cases and if is available, should be used sooner, then later.

Yep, that's why it's out there. The sooner it's given, the sooner the effects will start, usually in hours, but sometimes sooner.

 

[reaper]

It can work in as little as 15 minutes in severe bronco spasms.

For normal treatment it will work within 30-90 minutes. In severe cases, it is very fast acting. I have seen it work in under 10 minutes to take a asthma pt from no air movement to severe wheezing. Which them allowed the duoneb to take affect and do its job.

 

[Shishkabob]

Have you ever used it on a completely shut down asthma pt?

It does act rather quickly in these cases and if is available, should be used sooner, then later.

Yes, useful, but Epi is higher on my priority list over a steroid for what needs to be done NOW to prevent the worst outcome.

 

[vquintessence]

mc400,

Just out of curiousity, were you the one to communicate with OLMC? abckids already alluded to the question, but what was the wording on the patch that ended with OLMC denying the mag infusion?

 

[mc400]

Thank you, forgot to mention that once IV was established and we were e/r to the er I pushed 62.5 mg of solu-medrol along with 10cc/per kilo bolus and ended up giving a total of 375cc or so.

We have disposable cpap but only mask sizes for large and small adults, but the small is still too big. Had the inline set-up and BVM was next on the list. Without RSI the tube was going to be a real problem. ER was set up to RSI her upon arrival but she was slowly, really slowly improving and they held off. Pt ws transported out to the childrens hospital about 30 minutes farther away.

We tried to help educate the family as well, hoping next time they will not wait nearly as long to call 911 or seek help in some way. I did not like ths call at all, I had reactive airway disease as a child and vividly remember feeling like she was.

 

[abckidsmom]

Thank you, forgot to mention that once IV was established and we were e/r to the er I pushed 62.5 mg of solu-medrol along with 10cc/per kilo bolus and ended up giving a total of 375cc or so.

We have disposable cpap but only mask sizes for large and small adults, but the small is still too big. Had the inline set-up and BVM was next on the list. Without RSI the tube was going to be a real problem. ER was set up to RSI her upon arrival but she was slowly, really slowly improving and they held off. Pt ws transported out to the childrens hospital about 30 minutes farther away.

We tried to help educate the family as well, hoping next time they will not wait nearly as long to call 911 or seek help in some way. I did not like ths call at all, I had reactive airway disease as a child and vividly remember feeling like she was.

Were you wishing you could have used the CPAP for her?

 

[mc400]

No the rescue medic patched while I was getting the line. He outlined what we had pretty good making the impression of a very sick kid who was not responding well enough to any of the prvious treatments. I am not sure why exactly the Dr refused Mag, I did not have a chance to ask him but I will try next shift if possible. We had a hard time getting mag protocols at all for adults so they are probably even more apprehensive for peds? I have seen mag work wonders on adults who do not respond to combivent, epi, cpap, etc.

 

[mc400]

Yes I would have most likely used cpap if it was available. Only problem I see is how anxious this child already was and being able to get the mask on her..

 

[abckidsmom]

Yes I would have most likely used cpap if it was available. Only problem I see is how anxious this child already was and being able to get the mask on her..

Did you notice how long her expiratory phase was? Do you think that she had more problems moving air into her lungs or out of her lungs?

CPAP is not really the best idea for asthma (or whatever severe bronchospasm she's having). She's already got pretty high airway pressures, and adding to them is not going to be really helpful.

In her case, adding CPAP would have increased her tidal volumes, while at the same time making the expiratory phase be an even higher percentage of the total time of each ventilatory cycle, time that she was spending trying to breathe out against the 5 or 7 of PEEP that the CPAP mask added to the situation.

CPAP is a great tool, but not for a person in respiratory failure of a constrictive nature.

A quick google told me it's not competely unheard of, and won't be fatal, but it's not going to help, if you think about how it works, and what the physiology of her problem is to begin with.

 

[mc400]

She was breathing rapid with about the same amount of time for both phases. I would have liked to see an end tidal reading but our set up does not support using nebulized meds and the monitor on our truck is not compatable anywyas, which is a whole other can of worms we are fighting with everyday.

I would have probably given it a shot to see if it would help and possibly allow the neb'd meds to get in better. With the way she was breathing I could imagine most of the meds were wasted or spread around her oral cavity and not deep in her lungs.

We are supposed to use cpap on adults with bronchospam not resonding to high flow o2 and nebulized meds per our protocol but I do understand the issue at hand. Same thing with copd'rs with weak lungs. I transported a patient with a pneumo secondary to aggresive cpap application by a crew.

 

[abckidsmom]

She was breathing rapid with about the same amount of time for both phases.

This is key, though. She's so air-hungry that she's not even able to allow for complete exhalation. She was stacking breaths, and not exchanging the air. I'm surprised to hear that the phases were equal.

I'd have been just a little leary of it without full RSI ability, but it sounds like she needed just a whiff of some benzo, too, just to remove a little of the anxiety component.

 

[mc400]

I agree with the benzo, I would have liked to give the family some benzo's too lol.

 

[abckidsmom]

I agree with the benzo, I would have liked to give the family some benzo's too lol.

Right? Aerosolized benzos for the whole bunch!

I'm glad you shared this scenario, it's been a while since I have seen a sick kid IRL, it's nice to think this stuff through every once in a while.