HCMC - Hennepin County Medical Center

Emergency Medicine at HCMC
Survival Tips > Asthma

I. History and Physical Exam

A. Try in the history to get a feel for how bad their asthma has been in the past. Any prior intubation, ICU admissions, last prednisone burst, number of ED visits in the last year, what medications are used at home. Do they have trouble with SOB at night.

B. Did they run out of their medications?

C. What are their asthma triggers?

D. How long has their current attack been going on? Did it come on suddenly or slowly over the last few days? What medications did they use at home? Any URI associated symptoms? Productive cough, fever, or chills associated with this attack.

E. Any aspirin or NSAID allergy?

F. Physical exam – how much distress is the patient in? Watch them breathe and observe Insp:Exp ratio. Use of accessory muscles, nasal flaring, or intercostal retractions.

G. Lung exam – are they moving good air? Wheezing insp/exp and where in the lungs? Any crackles or other signs of consolidation?

H. If the patient is in great distress be sure to begin treating the patient while you are examining and talking to the patient.

II. Work-up and Treatment

A. Try to get a peak flow and oxygen sat prior to treatment.

B. Albuterol/Atrovent Nebs as needed. Try to listen to the patient between treatments and get a peak flow. It is important to continually reassess these patients.

C. Steroids – should be given early. Solumedrol 125 mg IV or Prednisone 60 mg PO. Have a low threshold to give steroids as asthma flares are primarily inflammation.

D. Other possible treatments include Magnesium IV, Terbutaline SQ, or Epinephrine SQ. Discuss the need for these with the senior or staff.

E. CXR – dependent on patient, but some indications include history of productive cough, fever, or patient not clearing with treatments.

III. Disposition

A. Home – be sure to refill any medications needed and if given steroids in ED send home with 5 day prednisone burst or longer with taper. Ensure close follow-up and stress the importance of returning if patient not improving at home.

B. Admission – asthmatics may be admitted to green medicine or MICU depending on severity of attack. Also, if they have a FP primary they should go to the family practice service. On the floor the patients can get Q4 hour scheduled Nebs with Q2 hours PRN.

C. If decision is to admit, be sure to continue treating patient while they remain in the ED.

For more information contact Richard O. Gray MD.