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How to Identify the Sick(er) Asthmatic

Matthieu DeClerck, MD and Haney Mallemat, MD
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Asthma is a common disease process and is also a common presentation to the Urgent Care setting. Most asthma exacerbations are easily controlled with inhaled Albuterol. But when a patient is having a severe asthma exacerbation the clock is ticking! Initiating therapy and immediate transfer to the Emergency Department is critical. Therapies that should be given if available include: Oxygen, Albuterol, Ipratropium, Epinephrine, Magnesium, and Steroids. Non-invasive ventilation, Terbutaline, and Ketamine should be considered as well when available.

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Ian L., Dr -

What of IV adrenalin dosing : ? - the 1ml in 1,000 or 1ml in 10,000 mixed in I litre saline run in at 25-100ml per minute = 25ug- 100ug adrenalin per minute ?

The other question is oxygen 6L per minute running the nebuliser .
Can be a danger with COPD / asthma as regards blunting hypoxic drive - I would hold Po2 by pulse oximetry at 88-92 as soon as possible .

Mike W., MD -

I would recommend against IV epi dosing in the urgent care - if the pt is that sick, they certainly need emergent transfer to the ED. The dose of epi would be 0.3mg IV (not SQ). Same goes for O2, if the pt needs that much oxygen, strongly consider ED tranfer. Thx for the note and certainly agree we don't want to blunt the resp drive in COPD patients, though if only during the nebulizer this would b unlikely. Thx Ian!!
M

Sara B., 8823815 -

Just wondering about using ipratropium? Is it really beneficial in the asthmatic? I currently do albuterol alone for the moderate asthmatic that I am treating in the UC. Thoughts? Thanks, Sara

Mike W., MD -

From Matt DeClerk:
Sara,

Thanks for your question. While Albuterol is first line and the most important medication to administer to an asthmatic patient (other than Epinephrine if they are crashing), Ipratropium is and important adjunct, especially in patients experiencing severe asthma exacerbation. Ipratropium is not meant to replace Albuterol, rather used as dual therapy (duoneb). Pts that have had good response to the combo of Albuterol + Ipratropium in the past should also be considered for dual therapy. That being said if you only have Albuterol available that is acceptable, realizing that pts that are having a severe asthma attack or are not responding appropriately to single therapy with Albuterol should be sent to the Emergency Department higher level of care.

Hope this answers your question.

Matthieu

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Off The Cuff Full episode audio for MD edition 169:22 min - 79 MB - M4AHippo Urgent Care RAP September 2019 Written Summary 681 KB - PDF

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