History and Patho
What information is pertinent from Jared's personal/ social history?
Family housing
asthma-related school absences
highly active
The mother and older sister arrive with the patient.
Albuterol
Beta 2 agonist
Relaxation of smooth muscle
Dilation of Bronchioles to improve airflow
What should your assessment focus on?
General appearance, Respiratory, Cardiac, and Neuro
What blood base lab studies are relevant?
WBC 10
Neutrophils %55
Hgb- 14.1
Situation
Jared is a 10yo AA male being admitted for an asthma exacerbation.
What relevant data is in Jared's history of the present problem?
10yo African American Male
Hx of asthma, with prior ICU admits
50% PEF
SOB
Ashen color and dark circles
Use of accessory muscles and chest tightness
Methylprednisolone
Systemic corticosteroid
Reduction of inflammation
treatment of acute asthma exacerbation
What assessment findings are concerning?
Ashen color
Speaking in short sentences
use of accessory muscles
wheezing + decreased breath sounds
moist forehead.
What other labs if any should we collect on Jared?
Viral Multiplex
COVID-19 swab
Blood gas
potentially urine
Background
Jared was in moderate to severe distress on arrival to the ED. He has been admitted to the ICU before for his asthma.
What is the pathophysiology of asthma?
Multiple cells experience inflammatory responses resulting in airway inflammation, and airflow restriction, which typically results in cough, wheeze, and SOB.
Fluticasone/Salmeterol
Steroid + long-acting beta2 agonist
Inflammation modulation and bronchodilation
Reduce resistance of airflow
What vital signs are important to note? Why?
temp
RR of 30
HR 120
SpO2 90%
pain 8/10
end-tidal CO2 30
Based on the provider's orders what should we do first?
oxygen
Q 1hr vitals
Albuterol
PIV
Steroids
Fluids
Assessment
Jared's vital signs have improved since receiving steroids and breathing treatments. He is still wheezing, but his narration has significantly improved since arriving.
What age is asthma typically diagnosed at?
Anytime after 2years of age.
Montelukast
Leukotriene modifier
blocks inflammatory and bronchospasm responses
long term control of asthma symptoms.
What does hyper-expansion/inflation of the airways signify?
Inflammation resulting in air trapping
What type of PPE should I be wearing? what if COVID is a concern?
At minimum a face mask. If COVID is a concern contact and droplet precautions with eye protection. N-95 mask required if giving nebulizer treatments
Recommendations
Jared will need to continue frequent breathing treatments as ordered, and will require frequent Resp assessments.
How can we quantify the severity of an asthma exacerbation?
PASS or CAB scoring
Ipratropium bromide
Anticholinergic Agent
Blocks the action of acetylcholine at parasympathetic sites in the bronchial smooth muscle causing bronchodilators, and reduce secretion production
increased airflow during periods of exacerbation
Should we be concerned about his EKG?
Yes, sinus tach suggests increased sympathetic nervous system involvement. We should monitor his heart rate as we begin to give medications.
If Jared does not improve what other medications or interventions should be considered?
High flow respiratory support like high flow NC or BiPAP- if sever possibly even and ET tube. Magnesium sulfate ( but isn't that just for pre-eclampsia?)
What other condition is often seen in patients who have a diagnosis of asthma?
Eczema