asthma pt - what would you do?

[g-emt]

Ok, so I am relatively new to being an emt and I had this call:

Arrive on scene... pt is on the floor, wheezing heavily... bystander says pt is having asthma attack... i give O2 with NRB, sit her up to help airway, and do a quick assesment... pulse in 90s, SpO2 94, RR upper 20s... no cardiac problems, and it is definetely an asthma attack according to pt...

I ask if she is prescribed an inhaler: she shakes her head no, bystander (older sibling) says she was sensitive to the med
I ask if she knows whether it was a steroid or albuterol inhaler that caused sensitivity: no
I decided to give albuterol anyways... her airway opened up and her O2 stats went back up... Later she was able to tell me she was allergic to steroids, but she still didnt know what gave her problems with the inhaler...


but i am worried, what if she was allergic to albuterol? i know hypersensitivity is a contraindication. Should i have given her the med knowing that she had a problem with previous inhalers, but not knowing if it was a steroid or albuterol inhaler she had a problem with? what would you have done?

 

[akflightmedic]

OK, you are new and asked for some armchair quarterbacking, so I will give it. Please bare in mind I am responding only to th einformation you have provided.

First, it says you "sat up the asthma patient to help with airway". Asthmatic patients are very rarely laying down or any other postion than sitting when they are truly in an attack. Remember the word "tripod" from class?

When an asthmatic is laying down, it is bad juju cause that means they are done, going to cease breathing pretty soon and I highly doubt one neb trmt would turn around a patient who has reached this point. They would not even be able to hold themselves up and actually recieve the treatment.

Then you say "bystander says....". Good rule of thumb is acknowledge the bystander but do not allow what they tell you to cause you to become tunnelvisioned. What does YOUR ASSESSMENT tell you....that is the important question.

Bystanders can easily influence an inexperienced provider down the wrong path, I have seen it many times. Be confident in yourself and competent in your knowledge and abilities.

Now as for the patient vitals...do those sound like a patient in serious distress? Pulse is not that fast, SPO2 is ok, and respirations are even in an ok range depending on presentation.

Then you say "definitely an asthma attack according to pt", well again I ask you...what does YOUR assessment tell you? Yes, patients should know their history and often do have it correct, but there are many out there that lie for attention or truly do not know what is going on.

OK, pet peeve time. It is NOT O2 "stat", it is O2 "sat" as in saturation not staturation. Please learn that so you dont say it in front of someone at the hospital and make yourself look further uneducated.

Now finally the med portion. You have a "known asthmatic" that does not have a rescue inhaler. Patient is unsure what she is or isnt allergic to and does not know why or which type of inhaler she had. It seems odd that any known asthmatic would not have an inhaler, epecially when they are prone to attacks serious as this one.

So, not knowing any of her allergy information, you decided to go ahead and give a neb treatment. Kudos to taking some intiative and making a decision, but did you consider the ramifications of what if she were alllrgic to it and you went ahead and killed her? Did you consider contacting medical control, a supervisor, anyone else that you could bounce the decision off of? I suggest med control of course, but did you?

After the med delivery, her airway opened and her sats increased....they increased from 94% to 97/98%?? What were her sats when you very first got there?

FYI, O2 sats are great but irrelevant. You can tell me so much more by noting physical changes in appearance and comfort levels than a machine with a number. Also, no where here did you mention auscultating lung sounds. This is so very important! You said you heard wheezing which is fine, but did you listen to where the wheezing was coming from?

Where it is coming from and whether it is inspiratory or expository wheezing is important. I have had patients fake wheezing before and a simple stethoscope could help you learn so much more about your patients condition. It also gives you a baseline to note actual improvement.

For example, if you tell me patient had wheezing in XYZ lobes inspiratory and expository pre neb treatment...and then follow up with wheezing diminished or resolved post treatment....that is more helpful than saying an O2 sat increased a few points. See what I mean? Also if you describe their overall apearance, color, body position, etc...this is more pertinent than a number off of a machine.

OK, so once she was able to talk and tell you it was a steroid inhaler that gave her problems, was she able to tell you what these problems were? Again, more important information either not asked or overlooked.

Finally, you ask what would I have done. If I were a basic, in your situation, I would of called med control. Once you have done that, all is well and you do what the doctor tells you.

One last thing to consider, do you think any of this may have been a panic attack or drama code?? This is a very real possibility, especially with the young females. A very thorough assessment could of revealed other possible causes. An thorough assessment also involves history gathering. What led up to this event, what was going on just prior, has she been having problems for several hours or days, or was this a sudden acute onset?

If this were a simple panic attack, you would not be the first to be fooled into thinking asthma first. It has happened before and will happen again, just learn from it.

 

[VentMedic]

I see you are an EMT-B, correct? I am going to approach this post cautiously since I do not know what other resources or training you have. And, definitely pay attention to akflightmedic's advice on calling medical control. That being said...

How old is this patient?
Is she still able to talk in complete sentences?
Do the wheezes cease momentarily after speaking?
Do you hear wheezes throughout?
What the med she was "allergic" to given in an emergency situation?
Who or where was she given the med?
Who diagnosed her with asthma?
How was she diagnosed with asthma?
At what age was she diagnosed with asthma?
Is she under a physician's care for asthma?
If so, is there a reason her physician did not give her another or any rescue inhaler? There are several on the market besides albuterol.
Or, was it an OTC inhaler like Primatene Mist?
When was her last asthma attack?
Has she ever been hospitalized for asthma?
Does she drink coffee or tea? (Xanthines that brings on similar side effects)

These are just some of the questions that I might try working into the conversation or assessment at sometime.

Many people mistake the common side effects for an "allergic reaction".
Palpitations either real or perceived, jitters, shakiness, etc.

Some people did have a sensitivity to the old CFC propellant formulation in MDIs. New MDIs are HFA and a said to create less sensitivity.

Many GP doctors hand out Combivent or Atrovent MDIs with out asking if the patient is sensitive to soy or peanuts. I have seen a couple of severe reactions for that reason. If Combivent switches to the HFA propellant, that will no longer be a problem. Atrovent is already HFA so the allergy to soy or peanuts no longer applies.

Was this a nebulized Albuterol treatment that you gave? Since this is administered over 7-8 minutes, you can stop it at any time.

I carry a picture list of all (or at least the most popular) MDIs on my clipboard. If the patient can not pick out the suspect in a line up, I get suspicious. The pictures of MDIs can be downloaded off the internet or at your local ALA office. Often people are get diagnosed with asthma by everyone from their hair dresser to mechanic. If they do have an inhaler, I check the script for their name and expiration date.

O2 Sats on a true asthmatic can be deceiving. In the early stages of the attack, the airways start to air trap creating a "PEEP" effect. This will actually keep the SpO2 higher but for the wrong reasons. Once the airways open the SpO2 may drop dramatically giving the Clinician a good scare if they are unfamiliar with treating asthmatics. If breath sounds and breathlessness are improved, the patient should recover to a higher SpO2 within a few minutes. However, if breath sounds and breathlessness have not improved then the patient may be in the decompensation phase.

Again, pay attention to the patient more than the pulse oximeter. The patient will give you more indication of trouble then the SpO2.

 

[Emtgirl21]

Dang asthma pt always causing problems. Vent and Akflightmedic are right if you have an asthma pt laying down then it is either not asthma or get ready to tube because they will not be breathing much longer.

 

[skyemt]

having allergy induced asthma, i can tell you a couple of things...

i have never had a bad attack, and been sitting in anything other than the classic "tripod" position...

but if it got so bad that i was lying down, i would be "circling the drain", so to speak, and you would see very different things, like cynaosis, poor muscle tone, etc...

i can not imagine a serious asthmatic not having a rescue inhaler, but if they didn't have one, they sure as heck would know why, and what they were sensitive to... it is a life-threatening situation...

finally, i have been in your exact situation, and my solution was to call med control... providing you have a good set of vitals and present illness history, they will be very helpful, and GREATLY reduces the chance of making a mistake, not to mention taking a whole heap of pressure off of you...

 

[medic001918]

Great post AK! I'm not sure there is really much more to add. Fortunately, this situation worked out for you even though it was a gamble.

I also have to agree with others that it doesn't sound like an asthma attack. The presentation and the picture you painted for us simply doesn't fit.

With experience, you'll find less patients able to pull one over on you. It happens to everyone from time to time though.

Shane
NREMT-P

 

[nsom9ac]

I can think of a couple of situations when an asthmatic wouldn't have an inhaler. the pt isn't at home and didn't take it with them, lost it and haven't replaced it yet, or non-compliant with getting rx filled such as what happens so often in underpriveledged areas (inner city).

my fiance's daughter (14 y/o) has moderately bad allergy induced asthma, mostly to pet dander so she never has a problem at home. so then her inhaler and nebulizer ends up getting lost somewhere in the forbidden abyss she calls a room, and when she goes to a friends place where there are pets she doesn't have an inhaler available.

 

[skyemt]

the reference was to a serious asthmatic not having one "prescribed" to them at all...

of course, they could be forgotten, empty, left in the car, etc. etc...

that's not what was being talked about...

 

[g-emt]

thanks guys,

i'm really learning a lot... i definetly realize that i should have considered the fact that this might not have actually been an asthma attack, but a panic attack. looking back it, i'm leaning towards panic attack... he body position and the fact that she complained of a lot of emotional stress (although emotional stress can trigger asthma, right?) and that she wasn't prescribed an inhaler (she said she hadn't had an attack in awhile).

I did question why she wasn't prescribed an inhaler, and to go into more depth she said it was because she hadnt had an attack in awhile and that she was "sensitive" to it. Now, the reason i decided to go ahead and use albuterol (which i should have explictly stated) w/o calling med control was that when i asked what happened when she used the inhaler in the past, she said it made he heart beat fast and made her jittery... so i figured even if it was an albuterol inhaler that made her feel this, what she thought was a problem was actually just an uncomfortable side effect...

but that being true or not, it still comes down to me not letting myself feel pigeonholed by the dispatch and the bystanders, and being able to look at the scene and ask myself "what does this really look like?"
and also not being afraid to call med control when in a questionable situation like that


that being said, thank a lot... i am really learning a lot and i am never going to make this mistake again... definetly going to start posting here more... such a great learning community...

 

[Airwaygoddess]

Very good posts, just remember that it is a learning process, it is better to ask questions and get answers, then to do the "I wish I would have asked that" dance. By the way, welcome to the tribe!!

 

[nsom9ac]

the reference was to a serious asthmatic not having one "prescribed" to them at all...

of course, they could be forgotten, empty, left in the car, etc. etc...

that's not what was being talked about...

My response was to the statement .... "i can not imagine a serious asthmatic not having a rescue inhaler".

 

[BossyCow]

My response was to the statement .... "i can not imagine a serious asthmatic not having a rescue inhaler".

Semantics - As an asthmatic (Reactive Airway Disease) I "HAVE" a rescue inhaler (several actually) but do I always have it with me? As the steroid inhalers improve it can lull us into a sense of false security because we haven't needed the dang thing in 3 months so why put it in that small purse that barely has room for my wallet but looks perfect with this coat. Stupid yes, but also a very common human error.

 

[VentMedic]

The patients that don't make alot of noise are the ones that concern me. If there are barely any breath sounds audible, this patient may be having serious problems if the other clinical signs correlate.

Of course, the ones that wheeze audibly and have every accessory muscle in action also get my immediate attention.

Also, don't always expect clear breath sounds or even clearer breath sounds after a 2.5 mg Albuterol treatment. It may takes days of steriods, continuous albuterol and heliox to get them through a respiratory crisis. And then, they may still have wheezing for a few more days after all that. The goal is not to let them wear out and go on a ventilator.

Also, many non-compliant asthma and COPD patients of other types are amazed in the pulmonary lab when they see the post-bronchodilator response and lung function they could be getting if they used their inhalers. They become acustomed to living short of breath. This includes both young and old patients. Often, I can get a 30% or > in lung funtion in these patient with just 3 puffs of Albuterol.

For many of these patients, you will rarely hear a wheeze. This is especially true with emphysema patients whose airways have lost too much elasticity to get a good wheeze going but they are still in need of bronchodilation.

The common comments made by many healthcare providers "You're not wheezing" or "You're sats are 99%" can skew an assessment and lead to a possible true respiratory emergency later. Look at all signs and symptoms before making a hasty judgement.

 

[BossyCow]

So to sum up VentMedic... my rule of thumb with respiratory patients seems to hold true. Don't trust 'em! The one that looks okay can crump on you suddenly. The one who looks bad can be stable all the way in and be sent home from the ER an hour later. They can start out bad and improve, seem minor and get serious. I just don't trust 'em.

 

[Emtgirl21]

Easy Bossycow easy! LOL. I have inhalers and nebs planted everywhere but thats just me. Please oh please new EMT's remember that a good O2 stat can be decieving like Vent said! (good man that vent) what was my third comment...hum oh yea, Also using a spacer with an inhaler can be a HUGE help. I didnt realize this until i have Pulmonary Function testing during an asthma attack and they did the test w/o a spacer and then with a spacer and I got much better results with a spacer. So anyways its bed time for me. You guys have a good day.

 

[Aileana]

yet another great post from Vent earlier on

From my (limited) experience,for this patient, i probably would have auscultated the chest first, to hear which fields the wheezes were coming from, and whether they were on inspiration or expiration, to determine whether in fact this was asthma. I can see how relevant medical history, or bystander guesses on what is going on can create tunnel visions towards that diagnosis, but the s&s do not sound like the 'typical' asthma attack. Having said that, since each patient is different, s&s can vary slightly in presentation from case to case...don't get caught up in textbook criteria either.

After that, the O2 NRB was a good idea, though I wouldnt have gone for the meds without asking the patient if they were actually allergic (never know if you can trust bystanders). Given the fact that she didn't know her inhaler, or have one at all, she's either very recently diagnosed (and relatively minor, given the lack of rescue inhaler), or not asthmatic. As Vent said, I'd suspect a panic attack or something similar.

 

[certguy]

asthma pt.

Newbies , you need to learn not to rely on fancy gadgets , but on your assessment of the pt. Being an asthma pt. myself , I got a whole new apprecitaion of what my pts. go through . Let your training and your intuition be your guide . Keep in mind there are sometimes acceptions to normal findings . Example ; When I have my attacks , I rarely wheeze . Nothing like having an RT and the DR argueing in front of me about whether or not I needed a breathing treatment based solely on this finding . The DR won out and the treatment did the trick . I agree , an asthma pt lying down is a BAD thing . Look at resp. rate and quality as well as skins . If they don't look good , don't be afraid to drop a nasal airway and assist ventilations . An asthma pt will usually be tripoding , and the best way to describe what they're feeling is having a chain wrapped around thier chest with guys pulling on both ends while trying to breathe through a stirring straw . This is one of the most scary feelings anybody can go through . Be prepared to treat the pt. emotionally as well as medically .

 

[katgrl2003]

One thing I've noticed with a lot of medical personnel, EMS and hospital based, is that they expect all asthmatics to be the same.

According to a nurse the last time I went to the ER for an asthma attack, I was faking. She told me "real" asthmatics have expiratory wheezes, not inspiratory, and it doesn't cause you to lose your voice. She also said further evidence of my faking was O2 sats of 99%.

Every member of my family has diagnosed asthma, exercised and allergy induced. I've had doctors, nurses, and EMTs all question whether or not I'm faking. They usually stop questioning when I start showing signs of oxygen deprivation.

I guess what I'm trying to say is not all patients present the same. If you suspect an asthma attack, treat it. All us oddballs out there will thank you.

-Kat

 

[skyemt]

as i posted earlier, i have allergy induced asthma, and as probably others can and have added, my attacks are rarely exactly the same... i usually get expiratory wheezes, but i have on many, many occasions had wheezes on inspiration as well, when the attack is further up the airway...

so, i've heard the "true astmatics have expiratory wheezes only" nonsense, and it is always said by someone who has never had an asthma attack...

also, early in the attack, as the airways inflame and get narrow, more air gets trapped in the lower airways and alveoli, as it can not effieciently get exhaled... this shows up sometimes as falsely high o2 sats... that is why it is important to treat the pt, not the machine...