Five Things to Keep in Mind When Treating an Asthmatic

Image from Alan Levine

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Author: Puja Gopal, MD
Emergency Medicine Resident
University of Illinois at Chicago
AAEM/RSA Publications Committee Member

Asthmatic patients present along a broad spectrum of severity. There are those who present with mild wheezing, have complete resolution with a single neb treatment, and go home with a refill of their albuterol inhaler. And then there are those patients who present unable to speak or breathe and become increasingly agitated and altered. Though presentations of asthmatic patients may vary greatly, there are some key things you can keep in mind with the asthmatics you see.

1. Monitor the patient and the 5 key vital signs closely – temperature, pulse, respiratory rate, blood pressure and oxygen saturation. Heart rate above 120 and respiratory rate above 30 are concerning for a severe asthma exacerbation. Also note that a decreasing respiratory rate can be concerning for the inability to maintain respiratory effort and possible decompensation. An oxygen saturation <90% is hypoxemia and requires your attention. Monitoring your patient’s mental status is of utmost importance to ensure they don’t become agitated or altered – both of which can occur with hypoxia and/or hypercapnia.[1]
   

Pre- and Post-Intubation Issues and Solutions

Photo Credit: Borls Ott - Flickr

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Author: Andrew V. Bokarius, MD
Emergency Medicine Resident
University of Chicago




There are a number of issues that may come up prior to, during, and after successful intubation. Let’s take a look at a few common problems and possible solutions.


 Pre-intubation:

• Can’t mask ventilate:
• Turn head to the side, consider oral/nasal airway or LMA.2 

• Can’t intubate, patient has a Grade 4/Mallampati Class 4 view:
• Change position or equipment, i.e., ear to sternal notch, B.U.R.P. maneuver (backward-upward-rightward-pressure or modified cricoid pressure), change blades, or consider a bougie, Glidescope, or other fiberoptic device.[1]  

Save a Life: Know the Precious P’s of Rapid Sequence Intubation

Photo: Wikimedia Commons

Author: Valery Victoria Rivas Cuesta, MSVI
Medical Student
Universidad Iberoamericana (UNIBE) School of Medicine

An emergency physician’s failure to secure the airway can rapidly lead to death or disability. In the emergency setting, patients are assumed to have a full stomach and be at risk for aspiration. Often, rapid-sequence intubation (RSI) represents the preferred method to secure the airway in the ED setting, as it results in unconsciousness (induction) and neuromuscular blockade (paralysis) rapidly thereafter.[1]

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The procedure has the following main goals: prevention of hypoxia, shortening the time between induction and intubation, minimizing aspiration risk, and improving first pass success.[1] This is achieved by the “ritual of the P’s”:[2]

ACE-Inhibitor Induced Angioedema

Author: Kaylinn Dokken, MSIII
Medical Student
Western University of Health Sciences

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ACE inhibitor (ACEi) induced angioedema is a potentially life-threatening complication of a very common class of medications, and is something every emergency physician should be prepared to manage. I personally witnessed three cases on a recent ICU rotation, and in one of the cases the patient required an emergent tracheostomy due to unsuccessful intubation attempts by the EM attending, an ICU attending, and the head of the anesthesia department.

Acute Severe Upper Airway Obstruction in Children

Author: Shane R. Sergent, DO

Upper airway obstruction (UAO) is potentially problematic in any population, but the incidence is more common in children given that they have small compliant airways. UAO in newborns is frequently from congenital abnormalities. In contrast, infants and young children have a spectrum of differentiated causes, the most common being acute infectious etiology. It is essential to recognize UAO early since increased work of breathing in these patients rapidly progresses to respiratory failure. This is because children have a decreased respiratory reserve patients. Therefore it is time critical to identify the cause and treatment.

Resident Journal Review: An Update on Airway Management in Emergency Medicine

Originally Published: Common Sense, Nov/Dec 2012

Original Authors: Authors: Michael Allison, MD; Michael Scott, MD; Kami Hu, MD; David Bostick, MD; Daniel Boutsikaris, MD

Edited by: Michael C. Bond, MD FAAEM; Jay Khapde, MD FAAEM

 There are few clinical skills as important to the emergency physician as emergency airway management. The field of airway management is constantly changing, and the practicing physician must keep abreast of the current trends in laryngoscopy, medication management, prehospital intubation, and the potential complications of intubation. Reviewed here are some of the key airway-related articles published over the past two years.

Direct Laryngoscopy Compared to Video Laryngoscopy

Board Review: The Pediatric Airway

Originally Published: Modern Resident, Jun/Jul 2010

Original Author: Karen Serrano, MD
University of Wisconsin Dept. of Emergency Medicine

Submitted by: Saadiyah Bilal, Publications Committee, Co-Chair
 
Managing the pediatric airway poses unique challenges for the emergency physician, requiring a good understanding of pediatric anatomy and familiarity with child-specific tools and approaches for emergency airway.
Children are more susceptible to airway obstruction than adults. One millimeter of edema in a small caliber pediatric airway (4mm diameter in a neonate) leads to dramatically increased airway resistance compared to the same amount of swelling in an adult (d=8mm) due to the effect of radius to the 4th power on rate of flow. The relatively large tongue of children can also collapse against the posterior pharynx, resulting in airway obstruction. Maneuvers such as the chin-lift or