8 y/o Severe brochospasm scenario

[Veneficus]

I would just like to point out.

The limit of "evidence" based medicine is that it is based around what works best for the most number of patients in a select group.

It is also based on very strict parameters of diagnosis and enrollment.

In medicine, but especially in field medicine, it is often difficult if not impossible to reach definitive conclusions on diagnosis. (Not that we shouldn't try.)

We must be very careful on absolute statements like "always" or "never."

Studies that establish practice guidelines in medicine are invaluable, however, it is also important to recongnize and understand the limitations of them.

One of the things I have noticed, as medicine becomes more fragmented in the effort of hyperspecialization, is that various specialties have stopped communicating or seeking the others advice.

Despite the "decreased complications" and "better outcomes", for various disease states, patients often have more than one disease and the treatments of these noncommunicating specialists often interfere with each other and cause undue patient confusion. Which I strongly suspect increases complications and creates worse outcome. (polypharm is a very good example.)

 

[Shishkabob]

Epi first line medication, IM for us, and swap the child over to our meds/neb at 8LPM. Establish IV, start mag infusion. When practical, administer methylprednisolone and small fluid bolus. Have a BVM and advanced airway equipment nearby. If the kiddo starts to decomp, BVM with neb attached...followed by intubation if needed.

Pretty much same as us, except we have IM/SQ OR IV Epi, depending on what we can get the quickest.

Just to point out a potential issue, how many people carry a pediatric CPAP mask? We have a 1 size first most set up, and I highly doubt it would seal on an 8yo.

We have large adult, small adult and pediatric.

 

[8jimi8]

continued reading and realized my post was completely unneeded.

 

[MrBrown]

continued reading and realized my post was completely unneeded.

Just like most of Browns

 

[HappyParamedicRN]

This makes me appreciate NH, where everything except The Heparin we carry for STEMIs is standing order!

Happy

 

[Smash]

Smash... our protocols are state-wide medical protocols which are pretty aggressive and science based. They are not created off of a single person's belief. Based on currently available data CPAP is being shown to be effective in the obstructive pulmonary group of patients. The physiology of why CPAP would be beneficial makes sense to me.

What science? Mobey posted some studies, including pretty much the only methodologically sound but nonetheless underpowered and not necessarily applicable to the field study. If your protocols are science based, you should be able to reference the science behind them, otherwise they are opinion.

The currently available data is not showing that CPAP is effective in acute asthma, it is not powered to. It has certainly shown that it is a promising treatment modality that should be investigated further, but it is a far cry from definitive or even universally accepted.

The physiology of CPAP does seem to make sense. But then the physiology of furosemide for cardiogenic pulmonary edema made sense, the physiology of bicarb in arrest made sense, MAST pants made sense, bretylium made sense, plavix makes sense, tPA for stroke makes sense... none of which means much at all.

I am all for research based EMS... I want validity for what we do. But at the same time people are going way overboard with touting what can be done or should be done based on this study or that study.

If we are not basing our practice off research, then what? Do we really want to continue with eminence based practice?

Who said were experimenting? CPAP for asthma has been studied if even only small scale, the data supports it, and anecdotally it works very well in a lot of cases. The suggestion of letting people progress to respiratory failure before deciding to act solely because we have no multiple, large, double-blind trials is crazy.

When the evidence does not exist to support it's use then it most certainly is experimenting, whether it is overtly in the form of a trial or not. That's fine if you are happy collecting data; in fact we need more of that, but to suggest that the data supports it's use as it stands is simply not true.

This makes me appreciate NH, where everything except The Heparin we carry for STEMIs is standing order!

Happy

Cool, can we discuss the evidence for heparin in STEMI now?

 

[para1medic]

8 year old Female. Pt in tripod position with obvious distress and working hard to breathe. 32 resp/min lungs sound coarse and very tight. Pt appears very tired... cap refill >3 seconds

That right there is all the assessment I need -- IMMEDIATE epi 1:1000 IM, then worry about starting a line. You've obviously got severe pediatric asthma with multi-system involvement: respiratory, neuro, and circulatory. Immediate Epi. Do not stop, do not pass go, do not waste time setting up your neb. Immediate Epi, then worry about starting a neb treatment and an IV and putting her on the monitor and getting orders for steroids and all that jazz.

EPI FIRST for pediatric respiratory with multi-system involvement.

 

[mc400]

I agree 100%. Hope to get our peds standing orders changed soon. Like stated Its alb/atro svn, patch for mag infusion. No epi even on the protocol......Why I do not know, it is what every doc says to do and wants.