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Approccio all’asmatico grave: un case report

Rescue Press 11 May 2021

La scaletta delle prorità di trattamento proposta dal Dott Betzner in caso di asma severa

  1. Oxygenation
    • FiO2 100% to start via assisted NRBM with 5 of PEEP (RR no more than 10/min)
  2. Epi (IM and IV)
  • Small child 0.15mg (1:1000) IM
  • Medium sized child 0.3mg (1:1000) IM
  • Large child/adult 0.5mg (1:1000) IM
  • Then 0.5-1cc 1:100,000 Epi IV or IO q1min slow push to effect 
    • Mixed as cardiac Epi from the 10mL amp of 1:1000, waste 9mL of it. Add the remaining 1mL to 9mL Normal Saline giving 1:100,000 or 10mcg/mL
  • Asthma/allergy kitchen sink
    • Diphenhydramine 50mg IVPB
    • Ranitidine 50mg IVPB
  1. When air is moving
  • Continuous nebs: salbutamol 5mg, ipratropium 0.5mg x 3 then q4hr
  • Steroid: methylprednisolone 2mg/kg or dexamethasone 0.6mg/kg
  • MgSO4 2-4g over 10min (25-50mg/kg)
  • +/- IV salbutamol 4mcg/kg IVP 15min if HR <120
  • Give 5-10min to turn around…if all that fails

Intubating and ventilating the crashing asthmatic

  • Keep patient sitting while preparing to intubate
  • Ketamine 1-2mg/kg IV
  • Succinylcholine 1.5mg/kg or rocuronium 1.5g=mg/kg
  • Forced exhalation before connection to circuit
  • Slow BVM ventilation &/or very conservative initial ventilator settings
  • Cautious CO2 reduction with permissive hypercapnea until lung function improves
    • RR 6-8 to reduce barotrauma
    • Low tidal volume (6-8mL/kg)
    • Low I:E ratio
  • NaHCO3 as needed to keep pH>7.2 (controversial)
  • May need to switch to pressure control mode if peak airway pressures or plateau pressure >40

If you can’t get airway pressures down and can’t oxygenate

  • Consider barotrauma
  • Maintain paralysis
  • Inhalational anesthesia can be effective
  • ECMO