Care of the Crashing Asthma Patient

Several things should be considered in the crashing asthmatic:

• First and foremost, there is very little date on how to manage the crashing asthmatic!
• Any sick asthma patient should have IV fluid replacement-these patients have tons of insensible losses. IV fluids may also help with post-intubation hypotension cause by compression of the vena cava.
• Many EM folks have left Ketamine in the dust for intubating an asthmatic....anecdotally, it works, but creates very sticky and tenacious lung boogers that are hard to suction. Why make your job even harder?
• Sounds like common sense, but RSI the patient in the position of comfort (usually tripod) and then quickly lay them back supine.
• Consider instituting the "kitchen sink approach" to asthma care. This includes beta agonists, anticholinergics, Mg, steroids, IVF, epi, nebulized Lidocaine, perhaps non-invasive ventilation, inhaled (yes, inhaled) steriods. Our job really begins once they have been tubed.
• Sounds corny, but consider a "bedside coach." Believe it or not, some really sick asthmatics can be talked through a severe, life-threatening exacerbation. This can be a nurse, tech, physician. Someone to talk to them during this crisis. It works sometimes.
• Any intubated asthmatic who goes into PEA arrest should not be declared dead unless bilateral needle decompressions and bilateral chest tubes have been performed.
• If an intubated asthmatic codes once intubated, consider the following: (1) disconnect from the ventilator and bag VERY slowly...4-6 breaths/minute or even slower! (2) Although controversial, some consider manual chest wall compression helpful in "getting rid" of trapped air. (3) Vigorous IVF-positive pressure ventilation worsens the patients hyperinflation which compresses the vena cava, and (4) consider needle decompression and then chest tube insertion