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ER30 Emergency Medicine
Medical Emergencies
Toronto Notes 2019
Table 19. Asthma Assessment and Management
Elements of Well-Controlled Asthma
Can Respir J 2010;17(1):15-24
• Daytime symptoms <4x/wk • Nocturnal symptoms <1x/wk • No limitation in activity
• No absence from work/school • Rescue inhaler use <4x/wk
• FEV1 <90% personal best
• PEF <10-15% diurnal variation • Mild infrequent exacerbations
Classifications
Respiratory Arrest Imminent
Severe Asthma
Moderate Asthma
Mild Asthma
Disposition
History and Physical Exam
Exhausted, confused, diaphoretic, cyanotic Silent chest, ineffective respiratory effort Decreased HR, RR>30, pCO2>45 mmHg O2 sat <90% despite supplemental O2
Agitated, diaphoretic, laboured respirations Speaking in words
No relief from β-agonist
O2 sat <90%, FEV1 <50%
SOB at rest, cough, congestion, chest tightness Speaking in phrases
Inadequate relief from β-agonist
FEV1 50-80%
Exertional SOB/cough with some nocturnal symptoms
Difficulty finishing sentences
FEV1 >80%
Management
100% O2, cardiac monitor, IV access
Intubate (consider induction with ketamine)
Short acting β-agonist (Ventolin®): nebulizer 5 mg continually ®
Short-acting anticholinergic (Atrovent ): nebulizer 0.5 mg x3
IV steroids: methylprednisolone 125 mg
Anticipate need for intubation Similar to above management Magnesium sulphate 2 g IV O2 to achieve O2 sat >92%
O2 to achieve O2 sat >92%
Short-acting β-agonist (Ventolin®): MDI or nebulizer q5min Short-acting Anticholinergic (Atrovent®): MDI or nebs x 3 Steroids: prednisone 40-60 mg PO
β-agonist
Monitor FEV1
Consider steroids (MDI or PO)
If the patient with tachydysrhythmia is unstable, perform immediate synchronized cardioversion
• dischargesafeinpatientswithFEV1orPEF>60%predicted,andmaybesafeifFEV1orPEF40-60% predicted based on patient’s risk factors for recurrence of severe attack
■ risk factors for recurrence: frequent ED visits, frequent hospitalizations, recent steroid use, recent exacerbation, poor medication compliance, prolonged use of high dose β-agonists
• β-agonistMDIwithaerochamber2-4puffsq2-4huntilsymptomscontrolled,thenprn
• initiateinhaledcorticosteroidswithaerochamberifnotalreadyprescribed
• ifmoderatetosevereattack,administerprednisone30-60mg/dfor5-10dwithnotaper
• counselonmedicationadherenceandeducateonuseofaerochamber
■ follow-up with primary care physician or asthma specialist
Cardiac Dysrhythmias
• seeCardiologyandCardiacSurgery,C16
Bradydysrhythmias and AV Conduction Blocks
• AVconductionblocks
■ 1st degree: prolonged PR interval (>200 msec), no treatment required ■ 2nd degree
◆ Mobitz I: gradual prolongation of PR interval then dropped QRS complex, usually benign
◆ Mobitz II: PR interval constant with dropped QRS complex, can progress to 3rd degree AV block ■ 3rd degree: P wave unrelated to QRS complex, PP and RR intervals constant
◆ atropine and transcutaneous pacing (atropine with caution)
◆ if transcutaneous pacing fails consider IV dopamine, epinephrine
■ long-term treatment for Mobitz II and 3rd degree block – internal pacemaker
• sinusbradycardia(rate<60bpm)
■ can be normal (especially in athletes)
■ causes: vagal stimulation, vomiting, myocardial infarction/ischemia, increased ICP, sick sinus node,
hypothyroidism, drugs (e.g. β-blockers, calcium channel blockers)
■ treat if symptomatic (hypotension, chest pain)
◆ acute: atropine ± transcutaneous pacing
◆ sick sinus: transcutaneous pacing
◆ drug induced: discontinue/reduce offending drug, consider antidotes
Supraventricular Tachydysrhythmias (narrow QRS)
• sinustachycardia(rate>100bpm)
■ causes: increased sympathetic tone, drugs, fever, hypotension, anemia, thyrotoxicosis, MI, PE,
emotional, pain, etc.
■ search for and treat underlying cause, consider β-blocker if symptomatic
• regularrhythm(i.e.notsinustachycardia)
■ vagal maneuvers (carotid massage, Valsalva), adenosine 6 mg IV push, if no conversion give 12 mg,
can repeat 12 mg dose once
■ rhythm converts: probable re-entry tachycardia (AVNRT more common than AVRT)
◆ monitor for recurrence
◆ treat recurrence with adenosine or longer acting medications
■ rhythm does not convert: atrial flutter, ectopic atrial tachycardia, junctional tachycardia
◆ rate control (diltiazem, β-blockers) and consult cardiology • irregularrhythm
■ probable AFib, atrial flutter, or multifocal atrial tachycardia ■ rate control (diltiazem, β-blockers)