A 7 year old girl is brought into the emergency room, having an asthma attack. The staff of the emergency department gives her three updraft treatments of albuterol and atrovent, and 125mg of Solumedrol. Since she is still complaining that she cannot breathe, the staff calls for a Critical Care ambulance to transport her to the children's hospital for further treatment.
Upon arrival, the critical care paramedic sees a child who is obviously tiring of her respiratory effort, and her vitals show it: Her SaO2 is 86% on 2 liters by cannula, Heart Rate is 152, BP is 102/64. Her EtCO2 (which the hospital emergency department does not have the equipment to measure) shows a waveform that is too flat to determine is the classic "sharkfin" is present or not, and has a level of 16mmHg.
The hospital is busy debating on whether to give her another albuterol and atrovent treatment, epiniephrine, or intubating her. The paramedic asks why they have not given her a smooth muscle relaxer like magnesium sulfate, and the nurse replies that the doctor was worried that it might lower the patient's blood pressure. Of course, he was perfectly willing to give a beta agonist like albuterol to a patient who wasn't exchanging enough air for it to work, and risk sending the already tachycardic patient's heart rate even higher. Epinephrine would also increase the tachycardia.
The scenario illustrates some big flaws in how hospitals treat respiratory problems:
- Hospital emergency rooms, for the most part, do not monitor capnography, even though it is the most effective way of measuring pulmonary gas exchange on a realtime basis.
- Doctors not being the all knowing, perfect beings that the medical profession would have us treat them like
- The doctor not realizing that intubation is NOT therapeutic to asthmatics. This is a small airway problem, and will not be resolved by putting a tube in the trachea.
In this scenario, the paramedic called medical control and requested and received orders for 25mg of magnesium sulfate over ten minutes. By the end of that ten minute period, her blood pressure was still 100/58, her heart rate was down to 122, SaO2 100%, and her capnograph showed a square wave at 38mmHg. Her lung sounds were clear, and she was breathing normally.
To everyone: We should be the masters of basic medical problems. Epi and albuterol are not magic fixes for everything respiratory.
To doctors: Medics occasionally know what they are doing
While Mag is indicated, so is Epinephrine. There should have been no debate about this in a patient 7 years old.
ReplyDeleteI'm still amazed, after a dozen years of having ETCO2 in the field that none of the EDs I transport to routinely monitor that in non intubated patients.
They are stuck in the long discredited paradigm of using spO2 as some sort of indicator of respiratory status.