EM ReSCu Peds 14: Status Asthmaticus
Brief Narrative Description of Case
Participants receive a call-in from EMS for a 6-year-old male who reported severe, worsening respiratory distress at home. He is known to have a diagnosis of severe persistent asthma and had been discharged from the hospital 2 weeks prior with an asthma exacerbation.
Learners will designate roles for the resuscitation and prepare medications and equipment for the anticipated scenario. When the patient arrives, severe respiratory distress should be immediately recognized. The patient should be placed on bedside monitors and given supplemental oxygen.
Bronchodilators are immediately initiated with albuterol, ipratropium, and IV steroids administered with no improvement in clinical condition. This should prompt escalation in medical management. Even if given IV magnesium, SQ terbutaline or epinephrine, continuous albuterol, and positive pressure ventilation, he continues to deteriorate. At approximately 10-13 minutes into the scenario, the patient suddenly becomes hypotensive, tachypneic, and hypercarbic, with alteration in mental status (manikin should moan, or report of only moaning to painful stimuli).
A team member begins bag-mask ventilation (BMV). The physical exam reveals asymmetric chest rise and decreased breath sounds on the left (right if this is what is reflected in the task trainer). Learners quickly recognize a pneumothorax and perform an emergency needle decompression while one member talks to the family. The patient has improvement in 2 saturation and overall hemodynamics.
Primary Learning Objectives
At the end of this simulation, participants should be able to:
- Identify signs/symptoms of impending respiratory failure in a pediatric patient (application)
- Construct a differential diagnosis for respiratory distress in a pediatric patient (synthesis)
- Construct and implement initial medical management of status asthmaticus (application)
- Interpret changes in vital signs and exam suggesting clinical deterioration secondary to a pneumothorax (evaluation)
- Demonstrate a needle decompression of a pneumothorax (application)
- Demonstrate focused history taking from a caregiver (application)
- Explain diagnosis and management to caregivers (synthesis)
- Demonstrate teamwork and closed loop communication (application)
Case Creators
Authors
- Ilana Harwayne-Gidansky, MD, MA, FAAP, CHSE
- Caitlin Keane-Bisconti, DO
Editors
- Muhammad Waseem, MD, MS, CHSE-A
- Rebekah Burns, MD
- Nicole Elliott, DO
- Ryan Thompson, MD, FACEP
- Yih Ying (Eva) Yuan, MD
Updated February 13, 2023
Critical Actions
Team-based actions:
- Identify team leader and member roles prior to patient presentation (pre-brief/ huddle)
- Prepare the room prior to patient arrival – nebs, medications, intubation equipment
- Deliver first-line medications immediately
- Deliver appropriate second-line medications after recognizing failure to improve on first-line medications
- Recognize tension pneumothorax and perform needle decompression
Individual actions:
- Assigns roles
- Correctly identifies and calls for first- and second-line medications
- Summarizes in a standard fashion every 2-5 minutes for team members
- Hands off to PICU in a standard fashion at the end of the case
- Prepares airway adjuncts including bag-valve mask, LMA, and/or oral airways
- Appropriately consents parent or guardian for needle decompression, explaining risk, benefits, and alternatives
- Gathers appropriate equipment
- Performs procedure quickly, safely, and correctly
- Appropriately doses medications in a weight-based manner
- Appropriate 2-person medication check
- Delivers medication in a closed-loop manner
- Documents time and actions during simulation
Setup
Chief complaint: Respiratory breathing
Patient age: 6 years old
Weight: 25 kg
Recommended Supplies
- Manikin: Child, ideally with the ability to perform needle decompression. Alternatively, may use a task trainer in conjunction with manikin, if manikin does not have capability.
- Moulage: None
- Resources: Pediatric reference card such as PALS card and/or length-based tape (e.g., Broselow Tape)
- Manikin set up: IV in place already with drainage system. Clothed or in hospital gown.
- Equipment:
- Monitors in room
- Large-bore angiocatheter in room and available along with 20- and 60- mL syringes
- Optional chest tube kit
- Supplemental oxygen via simple face mask, nasal cannula, nonrebreather
- Positive pressure ventilation equipment
- Intubation equipment in room and available
- Medications with dosing options (may vary by institution):
- Albuterol
- MDI: 90 mcg/puff 4-8 puffs every 20 minutes for 3 doses
- Nebulization: 0.15 mg/kg/dose (minimum dose: 2.5 mg/ dose) every 20 minutes for 3 doses then 0.15 to 0.3 mg/ kg/dose not to exceed 10 mg/dose every 1 to 4 hours
- Continuous nebulization: 10-30 mg/hour
- Ipratropium
- Nebulization: 0.25 to 0.5 mg (250 to 500 mcg) every 20 minutes for 3 doses, then as needed 0.25 mg (250 mcg) every 1 to 8 hours or 1.5 mg over 1 hour
- Nebulization solution with albuterol (ipratropium bromide 0.5 mg/albuterol 2.5 mg): 1.5 to 3 mL every 20
minutes for 3 doses, then as needed for up to 3 hours
- Steroids
- Prednisone/prednisolone (PO): Loading dose 2 mg/ kg/dose, then 1 to 2 mg/kg/day in 1-2 divided doses; maximum daily dose: 60 mg/day
- Methylprednisolone (IV): Loading dose: 2 mg/kg/dose, then 0.5 to 1 mg/kg/dose every 6 hours
- Dexamethasone (PO, IM, IV): 0.6 mg/kg once daily as a single dose or once daily for 2 days; maximum dose: 16 mg/dose
- Magnesium sulfate
- 25 to 75 mg/kg/dose IV as a single dose; maximum dose: 2,000 mg/dose
- Terbutaline
- PO: 2.5 mg three times daily; maximum daily dose: 7.5 mg/24 hours
- SubQ: 0.01 mg/kg/dose every 20 minutes for 3 doses; may repeat every 2 to 6 hours as needed
- Oral inhalation: 1 inhalation (0.5 mg) as needed; if not effective after 5 minutes may repeat dose
- Epinephrine (1:1000 at 0.01 mg/kg IM)
- Wt 7.5 to <15 kg: Dose 0.1 mg
- Wt 15 to <30 kg: Dose 0.15 mg
- Wt ≥30 kg: Dose 0.3 mg
- Dose may be repeated based on severity and response to initial dose
- Aminophylline IV
- Loading dose: 5.7 mg/kg/dose
- Maintenance dose/continuous IV infusion: Children 1 to <9 years: 1.01 mg/kg/hour
- Normal saline or Lactated Ringer’s bolus
- 20 mL/kg bolus as needed
- Albuterol
Supporting Files
- Chest radiograph 1 – Hyperinflation
- Chest radiographs 2A and 2B – Left and right-sided pneumothoraces
- Ultrasound image – Pneumothorax
- ECG
- Laboratory results
Participants/Roles
- Team leader
- Member: Airway/ breathing
- Member: Procedures
- Member: Bedside RN (or embedded participant)
- Member: Medication/ code cart (or embedded participant)
- Member (optional): History taker
- Member (optional): Ordering physician
- Member (optional): Documenter/Timekeeper
- Standardized patient (actor or faculty) to play patient’s parent
If there are not enough learners to perform the above roles, faculty members or other embedded participant can play a nurse, respiratory therapist, or tech.
* Team roles may need to be adjusted in order to suit local practices and norms
Prerequisite Knowledge
- Faculty
- PALS protocols
- General knowledge of emergency medicine
- Simulation implementation and debriefing experience
- Emergency medicine residents
- Local policies/procedures/protocols for status asthmaticus
- Familiarity with the procedures of needle decompression, deep sedation, and consenting for procedures
Case Alternatives
- Deviation from any first or second-line asthma treatment should prompt clinical deterioration (increased work of breathing, worsening tachypnea, and/or desaturations). The embedded participant may ask if this could be all from his asthma.
- First-line treatments include bronchodilator therapy and/or steroids. Second-line treatments include magnesium, terbutaline, epinephrine,
- If learners intubate the patient, increasingly high pressures are required as the patient becomes hypotensive and more hypercarbic. The patient improves with either paralysis or spontaneous modes such as pressure support ventilation in addition to needle decompression of the pneumothorax.
Milestones
PC1. Emergency Stabilization
PC2. Performance of Focused History & Physical Exam
PC3. Diagnostic Studies
PC5. Pharmacotherapy
PC7. Disposition
PC9. General Approach to Procedures
PC10. Airway Management
PROF1. Professional Values
ICS1. Patient Centered Communication
ICS2. Team Management
Resources
- Fox SM. Aminophylline for status asthmaticus. Pediatric EM Morsels. 2022: Aminophylline for Status Asthmaticus — Pediatric EM Morsels.
- Global Initiative for Asthma
- Nievas IF, Anand KJ. Severe acute asthma exacerbation in children: a stepwise approach for escalating therapy in a pediatric intensive care unit. J Pediatr Pharmacol Ther. 2013;18(2):88-104. PMID: 23798903
- Camargo CA Jr, Rachelefsky G, Schatz M. Managing asthma exacerbations in the emergency department: summary of the National Asthma Education and Prevention Program Expert Panel Report 3 guidelines for the management of asthma exacerbations. J Emerg Med. 2009;37(2 Suppl):S6-S17. PMID: 19683665
ITEM | FINDING |
---|---|
Overall Appearance | 6-year-old boy who is quiet, in respiratory distress, and has an IV access already established in left arm. (If using manikin with voice, can say ‘it hurts to breathe’, otherwise, the embedded participant is to report what the manikin is saying.)
|
HPI | Brief EMS report: 6-year-old male who reported severe, worsening respiratory distress at home. He is known to have a diagnosis of severe persistent asthma and had been discharged from the hospital 2 weeks prior with an asthma exacerbation. EMS arrived at the home and found the child to be awake and alert; however, he was in respiratory distress with tachypnea and hypoxia to 89%. One nebulized albuterol dose was administered and a peripheral IV was placed in the ambulance en route to the Emergency Department. If learners ask for specifics: The patient developed cold symptoms including cough, congestion, and low-grade fever (100.4-101oF) over the past 3 days. The mother has been giving his usual once daily medications (inhaled steroid and montelukast), as well as his rescue albuterol inhaler (which is reserved for worsening symptoms) every 4-6 hours. He seemed to respond well to this regimen over the first 2 days of illness. However, this morning the child woke up with a severe coughing fit. He vomited once after this coughing episode and the mother administered his albuterol inhaler. He did not recover as well as the mother wanted him after the treatment. He seemed to be working hard to breathe and couldn’t finish sentences without taking a deep breath. This prompted mom to call 9-1-1 for assistance. Of note, the patient has been a bit more tired than usual over the last 3 days, but he has been eating, drinking, voiding, and stooling as per usual. Additionally, the patient has a history of asthma for which he takes an inhaled steroid twice daily and oral Montelukast once daily. He uses an albuterol inhaler “when he needs it” which varies between 1-4 times per day depending on if he is ill with a cold. He wakes up almost every night due to a coughing fit and can only go back to sleep after taking his albuterol inhaler. Oftentimes, he must sit out of gym class because he cannot keep up with the other children without becoming short of breath. He was discharged from the hospital 2 weeks ago due to an asthma flare. This was his fourth hospitalization for his asthma and during this stay, he needed to take steroids by mouth and albuterol more frequently than he normally would. He didn’t need to be in the PICU during this hospital stay; however, the one preceding (last year) he was in the PICU and intubated. Prior to this, he was admitted twice on the general pediatrics floor. Other than his usual daily medications, he has needed steroids by mouth 3-5 times a year for the last 3 years. His asthma is typically triggered by colds, dust, and when he is around dad smoking. |
Past Medical/Surgical History | Multiple lifetime admissions, one PICU admission, one prior intubation |
Medications |
|
Allergies | Dust-mite, mold, ragweed; No known drug allergies |
Family History | Multiple family members with asthma |
Social History |
|
Initial Assessment (0-5 min)
Initial evaluation through administration of albuterol, ipratropium, and steroids (or just albuterol and 5 minutes)
Critical Actions
Team-based actions, upon hearing a potentially sick patient is arriving to the ED:
- Identify team leader and member roles prior to patient presentation (pre- brief/huddle)
- Prepare the room prior to patient arrival – nebulizer, medications, intubation equipment
- Deliver albuterol/ipratropium and steroids immediately
Individual actions:
- Bedside MD: Assesses patient, performs primary and secondary survey
- Bedside ‘RN’ or MD member(s):
- Orders and administers albuterol, ipratropium, steroids, oxygen
- Places on monitor
- Appropriately doses medications in a weight-based manner
- Delivers medication in a closed-loop manner
Physical Exam
ITEM | FINDING |
---|---|
Vital Signs | T: 37.5oC, HR: 140, BP: 100/60, RR: 24, SpO2: 89% on room air, Wt: 25 kg |
General | Quiet appearing, in respiratory distress, answers questions |
HEENT | No facial swelling, uvula midline and non-edematous |
Neck | Supple |
Lungs | Suprasternal, intercostal, and subcostal retractions; poor air entry bilaterally; faint wheezing; speaking single words |
Cardiovascular | Tachycardic, normal S1/S2 |
Abdomen | Soft, non-tender, non-distended, no organomegaly |
Neurological | No deficits |
Skin | Pale but warm, capillary refill <2 seconds |
Back | Non-tender. No step-offs. No crepitus. |
Other | If asked, MAY provide a local, institutional pediatric asthma scoring tool in the severe range |
Instructor Notes: Changes and Case Branch Points
INTERVENTION / TIME POINT | CHANGE IN CASE | ADDITIONAL INFORMATION |
---|---|---|
0-2 minutes: Patient arrives, placed on monitor, hooks up IV to fluids, and supplemental oxygen via nasal cannula administered | No change *If no O2 administered, the patient desaturates and becomes more tachypneic (RR 30, SpO2 85%). | |
0-5 minutes: First-line medications given (albuterol/ipratropium, steroids) | No change *If medications are not called for by 3 minutes, the patient desaturates and becomes more tachypneic (drop by 10% in sat and increase by 20% RR for each action not performed). | |
After albuterol, ipratropium, and steroids administered | Proceed to Stage 2. | Incorporate a “time advance” of about 30 minutes for administration of medications that may take longer to get fully delivered (i.e., once albuterol is administered, it is OK to assume it runs for the entire duration). |
Initiation of Second-Line Medications
Administration of albuterol, ipratropium, and steroids through 10 minutes into case (approximately minutes 5-10)
Critical Actions
- Call for additional resources
- Give at least 2 second-line medications
- Initiate noninvasive ventilation
Physical Exam
ITEM | FINDING |
---|---|
Vital Signs | T: 37.5oC, HR: 150, BP: 90/50, RR: 30, SpO2: 90% on oxygen |
Exam Changes | Mild worsening of RR. No significant exam change. |
Instructor Notes: Changes and Case Branch Points
INTERVENTION / TIME POINT | CHANGE IN CASE | ADDITIONAL INFORMATION |
---|---|---|
At minute 5-9: Patient gives second-line medication:
There may be institutional variation. | If at least 2 medications are given, oxygen saturations rise to 93% for 1 min, then fall to 85%. Updated vital signs:
| Learners must give at least 2 second-line medications between 5-10 minutes. By 7 minutes, if no second- line medications are given, change vital signs to:
By 9 minutes, if 0 or 1 second-line medication is given, change vital signs to:
|
At minute 9: Sudden worsening | Develops sudden worsening of respiratory distress. Appears anxious, saturation drops to 85%, RR increases to 40. Proceed to Stage 3. | |
Standard institutional communication tools utilized | If not performed, the embedded participant or facilitator may ask for a summary. | |
10 minutes into the case | Proceed to Stage 3. |
Pneumothorax
10 minutes through needle decompression (approximately minutes 10-15)
Critical Actions
- Call for additional resources (if not already completed)
- Recognize pneumothorax
- Perform needle decompression (team member)
- Give news to parent (team member)
- Maintain global perspective (team leader)
Physical Exam
ITEM | FINDING |
---|---|
Vital Signs | T: 37.5oC, HR: 165, BP: 70/40, RR: 50, SpO2: 85% on oxygen |
Exam Changes |
|
Instructor Notes: Changes and Case Branch Points
In this stage, the patient fails to improve with first-line medications.
INTERVENTION / TIME POINT | CHANGE IN CASE | ADDITIONAL INFORMATION |
---|---|---|
At 10-12 minutes: Sudden change in respiratory status |
| Embedded participant asks, “He’s looking worse, what’s happening?” |
Team recognizes tension pneumothorax |
| If no recognition of tension pneumothorax by minute 15, the patient loses consciousness and becomes apneic despite any additional interventions. |
Gives IV fluid bolus |
| |
Calls for CXR/ultrasound | CXR/ultrasound should not delay needle decompression. | |
Obtains needle for tension pneumothorax decompression | ||
Optional:
| ||
Needle decompression performed | Improvement in vital signs to:
| If >3 minutes elapse before the team mobilizes for needle decompression, the patient becomes apneic, oxygen saturations decline from 85% to 70%, HR increases from 165 to 180, and BP drops to 65/30. Consider using a task trainer for needle decompression and/or chest tube placement. |
Pneumothorax is not recognized by minute 12 | Standardized parent involvement | Parent asks, “Do you think he might have a pneumothorax?” |
Case Conclusion
Resolution after needle decompression
Critical Actions
- Sign-out to PICU team
- Discussion of further treatment and/or contingency planning (e.g., intubation, ketamine, chest tube)
Physical Exam
ITEM | FINDING |
---|---|
Vital Signs | T: 37.8oC, HR: 150, BP: 90/40, RR: 24, SpO2: 95% on oxygen support |
Exam Changes |
|
Identify signs/symptoms of impending respiratory failure in a pediatric patient (application)
- Respiratory failure: Condition in which the body’s respiratory system is unable to oxygenate, eliminate carbon dioxide, or a combination of both.
- The clinical presentation varies depending on the degree of hypoxemia and hypercapnia; however, children commonly demonstrate signs/symptoms of increased work of breathing (tachypnea, nasal flaring, grunting, head bobbing, retractions, etc).
- Assessing a child with respiratory failure should first involve determining the need for emergent intervention. Learners can achieve this by assessing the vital signs, work of breathing, ability for the child to protect his or her airway, level of consciousness, etc.
Construct a differential diagnosis for respiratory distress in a pediatric patient (synthesis)
After or during the stabilization of the patient’s airway, a comprehensive history and physical is necessary to evaluate for possible etiologies of the patient’s respiratory failure. Factors such as prematurity, chronic medical diagnoses, anatomical abnormalities, associated symptoms, or events leading up to presentation can fine tune the differential diagnoses.
Construct and implement initial medical management of status asthmaticus (application)
Background
- Status asthmaticus: Acute severe bronchospasm unresponsive to
initial therapy with bronchodilators - Prevalence:
- Overall prevalence is 10% in pediatric population
- Increased risk of mortality related to:
- Teenage years
- Current or recent long-term steroid use
- Previous hypoxic syncope or seizure from asthma
- Recent (within 1 month) ED visit or hospitalization
- More than 2 admissions or 3 ED visits in past year
- Genetic, ethnic, and socioeconomic factors
- Risk factors for near fatal asthma:
- History of sudden, severe exacerbations
- Previous intubation for asthma or ICU admission
- 2 admissions in previous 12 months
- 3 ED visits in previous 12 months
- Current or recent use of systemic steroids
- Use of >2 canisters of bronchodilator per month
- Difficulty recognizing symptoms
- Psychiatric disorders
- Urban residence, socioeconomic status
- Illicit drug use
- Significant comorbid conditions
- Certain genetic polymorphisms ((Grunwell et al., 2018))
Treatment
- Targets alleviating both hypoxia and airway obstruction
- Oxygen: Target O2 to relieve hypoxia
- Mechanism usually related to V/Q mismatch
- Inhaled beta agonists
- Well established initial treatment, often used in combination with ipratropium – preferred as initial therapy (Griffiths & Ducharme, 2013)
- Albuterol = selective to beta 2, older medications are often non-selective
- MDI vs. nebulized beta agonists (Kerem et al., 1993)
- Systemic beta agonists
- SQ epinephrine or SQ/IV terbutaline: Consider in patients unresponsive to nebulized therapy, in uncooperative patients, and in refractory intubated patients
- Adverse effects/ monitoring: 10% have troponin leak, may have tachyarrhythmias
- Evidence showing benefit is limited but may decrease incidence of progressive respiratory failure and subsequent need for invasive mechanical ventilation. (Doymaz, Schneider, & Sagy, 2014)
- Steroids
- The use of steroids within one hour of ED presentation for children in status asthmaticus reduces the need for hospitalization and possibly duration of illness (Rowe, Spooner, Ducharme, Bretzlaff, & Bota, 2001)
- No difference between prednisone 2 mg/kg/day x5 days and dexamethasone 0.6 mg/kg/day x1-2 days (Keeney et al., 2014)
- No advantage to a specific regimen of steroids in a 2016 systematic review (Normansell, Kew, & Mansour, 2016)
- Anticholinergics
- Bronchodilation results from the blockage of acetylcholine receptors at the neuromuscular junction of bronchial smooth muscle
- Thought to have less of a bronchodilator effect and slower onset of action than beta-agonists
- Effective in conjunction with beta-agonists
- Cochrane review showed no difference in LOS but did not evaluate ICU patients. (Vezina, Chauhan, & Ducharme, 2014)
- Magnesium sulfate (IV)
- May reduce the need for hospitalization for children presenting to the ED with moderate to severe asthma exacerbations (Blitz et al., 2005; Cheuk, Chau, & Lee, 2005; Griffiths, Kew, & Normansell, 2016; Silverman et al., 2002; Singh, Gaur, & Kumar, 2008)
- Variably used, however, likely provides benefit when used as an adjunct to bronchodilator therapy and steroids
- Mechanism:
- Decreases Ca++ mediated smooth muscle contraction • Stabilizes mast cells, possibly decreases histamine release
- Side effects: Flushing, nausea, fatigue, somnolence, areflexia, respiratory depression, arrhythmias, hypotension, though in one study these were relatively uncommon. (Graff, Stevenson, & Berkenbosch, 2019)
- Pearl: Keep Mg levels 3.5-4 mg/dL. (Glover, Machado, & Totapally, 2002)
- Advanced non-invasive respiratory support
- Nasal High Flow: may improve work of breathing, may be more comfortable than NIV. Shown to be safe and feasible with low failure rate, and may reduce time on continuous albuterol but not LOS. (Baudin et al., 2017; Gates et al., 2021)
- Non-invasive ventilation (CPAP/BiPAP)
- Improves alveolar ventilation and allows for muscle relaxation
- Mechanism of action:
- Pressure thought to reduce premature airway closure point (decreases intrinsic and expiratory pressure/auto-peep) inspiratory work load
- Though to improve the delivery of aerosolized albuterol to poorly ventilated
- May reduce the premature airway closure point,
reducing intrinsic end expiratory pressure and subsequently the inspiratory workload (Venus, Cohen, & Smith, 1988)
- Contraindications: Poor patient cooperation, inability to supply high FiO2, hypercapnia, excess respiratory secretions, need for immediate intubation
- Risk of barotrauma: “Breath stacking” from positive pressure ventilation in the context of severe airway obstruction and air trapping—may cause pneumothoraces, though no major adverse events noted in one study. (Basnet et al., 2012; Carroll & Schramm, 2006; Carroll & Zucker, 2008; Usala & Wilson, 2022)
- Aminophylline
- Mechanism of action:
- Phosphodiesterase inhibitor, increasing cAMP binding–> bronchodilator and pulmonary vasodilator. Sustained improvement in oxygenation, hastened recovery, less tachypnea when compared with terbutaline. (Fox, 2023 Mitra, Bassler, Watts, Lasserson, & Ducharme, 2005; Singhi, Grover, Bansal, & Chopra, 2014; Stulce, Gouda, Said, & Kane, 2020;; Yung & South, 1998)
- May have lower odds of intubation and mechanical ventilation in African-American patients. (Stulce et al., 2020)
- Adverse effects: Vomiting, seizures, small therapeutic window
- Must monitor levels
- Mechanism of action:
- Ketamine
- Mechanism of action:
- Bronchodilator; releases endogenous catecholamines
- Releases smooth muscle by activating NMDA receptors in the lung
- Adverse effects: Laryngospasm, increased secretions, acute delirium/hallucinations
- In the ED, may improve severity index, (Denmark, Crane, & Brown, 2006; Jat & Chawla, 2012; Petrillo, Fortenberry, Linzer, & Simon, 2001), although a Cochrane review concluded that there was not enough evidence to draw strong conclusions (Jat & Chawla, 2012).
- Mechanism of action:
- Heliox
- Mechanism of action:
- May improve delivery of albuterol to small airways by reducing airway resistance
- Adverse effects: None
- Evidence: Kim et al. showed that children treated with continuous albuterol delivered by heliox showed greater clinical improvement than those treated with oxygen alone delivered albuterol. Differences were evidenced by pulmonary index (measured at 30-minute intervals) at 125 minutes post-randomization (Kim et al., 2005).
- Mechanism of action:
- Inhaled Anesthetics
- Case reports demonstrate some success, no trials to support more widespread use (Rehder, 2017).
- IV Antibiotics
- No evidence to support the use of antibiotics for acute asthma exacerbation (Rehder, 2017).
Interpret changes in vital signs and exam suggesting clinical deterioration secondary to a pneumothorax (evaluation)
- Pneumothorax: Accumulation of air in the space between the visceral and parietal pleura in the chest cavity resulting in impair oxygenation and/or ventilation
- Etiologies may include traumatic, spontaneous, or iatrogenic
- Signs, symptoms, and exam findings of a pneumothorax can vary from patients being asymptomatic to shortness of breath, chest pain, asymmetric chest rise, hypoxia, hypotension, bradypnea, altered mental status, and other signs of clinical decompensation.
- Learners should have a high clinical suspicion for pneumothoraces in patients demonstrating acute changes as above.
Demonstrate a needle decompression of a pneumothorax (application)
- Symptomatic patients with stable vital signs may be eligible for needle aspiration (or insertion of a small-bore catheter), as opposed to those with unstable vital signs who may require a larger catheter.
- Concurrent treatments may also include supplemental oxygen, serial chest radiographs, and pain control.
Demonstrate focused history taking from a caregiver (application)
- Components of history taking: Past medical history, surgical history, family history, medications, allergies, social history, vaccination history
- For this scenario, obtaining an asthma history with the following components is of utmost importance:
- Frequency of albuterol use
- Last albuterol use
- Controller medications
- Hospitalizations/ ED visits related to asthma
- Frequency of oral steroid courses
- Prior PICU stays or intubations
Explain diagnosis and management to caregivers (synthesis)
If personnel are available, one member of the team may stay with the family to gather history and explain interventions. Information should be relayed to the family using layperson’s terms.
Demonstrate teamwork and closed loop communication (application)
Teams may use different frameworks to improve team dynamics and communication. Below are a few definitions that may be helpful to discuss, adapted from the AHRQ TeamSTEPPS Pocket Guide.
- Brief: Short session prior to start of encounter to share the plan, discuss team formation, assign roles and responsibilities, establish expectations and climate, anticipate outcomes and likely contingencies
- Huddle: Ad hoc team discussion to re-establish Situation Awareness; designed to reinforce plans already in place and assess the need to adjust the plan
- Callout: A strategy used to communicate critical information during an emergent event. Helps the team prepare for vital next steps in patient care. (Example: Leader- “Airway status?”; Surveying provider- “Airway clear”; Leader- “Breath sounds?”; Surveying provider- “Breath sounds decreased on right”)
- Check-back: A closed-loop communication strategy that requires a verification of information ensuring that information conveyed by the sender is understood by the receiver as intended. The sender initiates the message; the receiver accepts it and restates the message. In return, the sender verifies that the re-statement of the original message is correct or amends if not. (Example: Leader- “Give diphenhydramine 25 mg IV push”; Med Prep- “Diphenhydramine 25 mg IV push”; Leader- “That’s correct”)
- SBAR: A framework for team members to structure information when communicating to one another.
- S = Situation (What is going on with the patient?)
- B = Background (What is the clinical background or context?)
- A = Assessment (What do I think the problem is?)
- R = Recommendation (What would I do to correct it?)
- Situation monitoring: The process of continually scanning and assessing a situation to gain and maintain an understanding of what is going on around you.
- Situation awareness: The state of “knowing what’s going on around you.”
- Shared mental model: Result of each team member maintaining situation awareness and ensures that all team members are “on the same page.” An organizing knowledge structure of relevant facts and relationships about a task or situation that are commonly held by team members.
- STEP: A tool for monitoring situations during complex situations. A systematic method to review Status of patient, Team members’ performance and status, Environment, and Progress towards goal.
- Cross-monitoring: A harm error reduction strategy that involves 1. Monitoring actions of other team members 2. Providing a safety net within the team. 3. Ensuring that mistakes or oversights are caught quickly and easily. 4. “Watching each other’s back.”
- CUS: Signal phrases that denote “I am Concerned,” “I am Uncomfortable,” and “This is a Safety Issue.” When spoken, all team members should understand clearly not only the issue but also the magnitude of the issue.
Bibliography
- Basnet S, Mander G, Andoh J, et al. (2012). Safety, efficacy, and tolerability of early initiation of noninvasive positive pressure ventilation in pediatric patients admitted with status asthmaticus: a pilot study. Pediatr Crit Care Med, 13(4), 393-398. doi:10.1097/PCC.0b013e318238b07a. PMID: 22067982.
- Baudin, F., Buisson, A., Vanel, B., Massenavette, B., Pouyau, R., & Javouhey, E. (2017). Nasal high flow in management of children with status asthmaticus: a retrospective observational study. Ann Intensive Care, 7(1), 55. doi:10.1186/s13613-017-0278-1
- Carroll, C. L., Sala, K. A., Zucker, A. R., & Schramm, C. M. (2012). Beta-adrenergic receptor polymorphisms associated with length of ICU stay in pediatric status asthmaticus. Pediatr Pulmonol, 47(3), 233-239. doi:10.1002/ppul.21544. PMID: 21905268.
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Download Case 14 supporting files
Notes:
- Chest X-ray #1 Interpretation: The CXR shows mild hyperinflation of the lungs, otherwise normal. Image from Dr. Rebekah Burns.
- Chest X-ray #2 and #3 Interpretation: The CXR shows a left- and right-sided tension pneumothoax. Depending on the available task trainer, the patient may develop either sided pneumothorax.
- Lung Ultrasound Interpretation: Pneumothorax
- ECG Interpretation: ECG with sinus tachycardia and very low voltage in the precordial leads
For the embedded participant playing the patient’s parent
Case Background Information
Your son has a history of asthma and was recently discharged from the hospital due to a “bad asthma flare.” You typically give him an inhaled steroid medicine and oral medicine daily; however, despite these therapies, he developed difficulty breathing over the last day. This is how his usual asthma flares start.
Who are the Learners?
Emergency medicine residents (various stages of training at first, second, third, and possibly fourth years)
First year residents can gather a history and perform physical examinations on patients. However, their medical knowledge and familiarity with pediatric medical treatments and procedures likely is limited. These skills become more refined and developed with each year of training. For the purposes of this simulation, assume learners are in their first or second year of residency training.
Standardized Patient Information
Your 6-year-old with a known diagnosis of asthma developed cold symptoms including cough, congestion, and low-grade fever (100.4- 101oF) over the past 3 days. You have been giving his usual once daily medications (inhaled steroid and montelukast), as well as his rescue albuterol inhaler (which is reserved for worsening symptoms) every 4-6 hours. He seemed to respond well to this regimen over the first 2 days of illness. However, this morning your child woke up with a severe coughing fit. He vomited once after this coughing episode and you administered his albuterol inhaler. He did not recover as well as you wanted him after the treatment. He seemed to be working hard to breathe and couldn’t finish sentences without taking a deep breath. This worried you and you called 9-1-1 for assistance.
Of note, your son has been a bit more tired than usual over the last 3 days, but he has been eating, drinking, voiding, and stooling as per usual. Upon arrival to the ED, you are concerned about your son’s appearance and increased work of breathing. Allow the team to assess your child and verbalize their thoughts to one another.
Patient Information
(Please remember not to offer any of this information, but when asked please respond while remaining in character.)
- CHIEF COMPLAINT (your response to open-ended questions such as “what’s going on?” or “what can we do for you? Or “what happened?”): “He is having a hard time breathing.”
- AGE: 6 years old
- ADDITIONAL HISTORY: He has a history of asthma for which he takes an inhaled steroid twice daily and oral montelukast once daily. He uses an albuterol inhaler “when he needs it” which varies between 1-4 times per day depending on if he is ill with a cold. He wakes up almost every night due to a coughing fit and can only go back to sleep after taking his albuterol inhaler. Oftentimes, he must sit out of gym class because he cannot keep up with the other children without becoming short of breath. He was discharged from the hospital 2 weeks ago due to an asthma flare. This was his fourth hospitalization for his asthma and during this stay, he needed to take steroids by mouth and albuterol more frequently than he normally would. He didn’t need to be in the PICU during this hospital stay, however, the one preceding (last year) he was in the PICU and intubated. Prior to this, he was admitted twice on the general pediatrics floor. Other than his usual daily medications, he has needed steroids by mouth 3-5 times a year for the last 3 years. His asthma is typically triggered by colds, dust, and when he is around dad smoking.
- PAST MEDICAL HISTORY: Asthma, obstructive sleep apnea, seasonal allergies
- SOCIAL HISTORY: Lives at home with mother, father, grandmother, older sister, one cat, and one dog. Father smokes outside the home.
- FAMILY HISTORY: Mother and older sister with asthma. Father with no known medical diagnoses. Paternal grandfather with lung cancer. Maternal grandmother with high blood pressure and type 2 diabetes.
- PAST SURGICAL HISTORY: Tonsillectomy and adenoidectomy at 4 years old due to sleep apnea
- MEDICATIONS: Inhaled corticosteroid twice daily, montelukast once daily, albuterol inhaler as needed
- ALLERGIES: No known drug allergies
- IMMUNIZATIONS: Up-to-date although no flu shot this season
- FEEDINGS: Regular diet, no restrictions
- BIRTH HISTORY: Full term male born normal vaginal delivery. Normal pregnancy without complications. Unremarkable newborn course.
Potential Dialogue
IMPORTANT: Do not offer unsolicited information. Please allow the learners to ask questions. Do not offer information unless they ask you.
Things you could say without being asked:
- “He was doing fine the past 3 days when I gave him his inhaler, but this is much worse.”
- “Someone tell me what is going on!”
- “Why is he not getting better?”
Things you might say triggered by events in the scenario:
EVENT | YOUR POTENTIAL RESPONSE |
---|---|
If the team does not proceed on to first-line asthma medications (albuterol and steroids) | “Do you think this could all be related to his asthma?” or “This is what happens when he has a bad asthma attack! Do something!” |
If the team fails to proceed to second-line asthma medications | “Are there any other medications that will help his breathing?” or “He needs more breathing medications!” |
When your child becomes unresponsive and if the team fails to recognize this change | “He just passed out! What else is going on?” |
If the team fails to recognize a pneumothorax | “Why is his chest moving like that?” |
Learners are given information from EMS regarding the patient en route for respiratory distress. They then assign roles preemptively and begin to prepare the resuscitation room in the ED. This may include setting up bedside monitors, gathering medications, IV access supplies, supplemental oxygen and airway equipment. Upon arrival, the team leader asks another team member to perform a primary survey of the patient. The team immediately recognizes the child’s respiratory distress, places him on a cardiac monitor and pulse oximetry, examines the peripheral IV placed by EMS, and deems it to be intact. They identify the patient to be tachycardic, hypoxic, tachypneic, and wheezing on physical exam. This prompts the team to administer first-line medications (supplemental oxygen, albuterol, steroids, and ipratropium). While initial interventions are taking place, one team member is assigned to gather more history from either an embedded participant or EMS. This information is communicated to the team using standardized institutional communication tools.
Despite first-line therapy, there is no clinical improvement in the patient’s condition. This prompts the team to escalate care and provide second line therapy including magnesium, terbutaline, aminophylline, epinephrine, and/or non-invasive positive pressure ventilation. These interventions also provide no relief, and the patient suddenly develops hypotension, tachypnea, hypercarbia, and altered mental status. The team begins bag valve mask ventilation. On re-examination, right-sided decreased breath sounds with asymmetry in the patient’s chest rise are noted. With this information, learners are suspicious of a pneumothorax and might order a STAT chest x-ray which confirms this clinical suspicion, although needle decompression without imaging is warranted. An emergent bedside needle decompression is performed, which results in the patient’s clinical improvement. A team member is designated to speak with the family member during these events to update and obtain consent. Once stabilized, a team member calls the PICU to give sign out.
Anticipated Management Mistakes
- Failure to recognize non-improvement in a critically ill asthmatic patient: The absence of improvement is sometimes more difficult to detect than other scenario branch points. In this case, a lifesaving statement from an embedded participant may help keep the scenario on track.
- Failure to diagnose tension pneumothorax: Some learners may note shock but be unable to effectively diagnose tension pneumothorax. In this case, an embedded participant may be helpful by reporting jugular venous distention, tracheal deviation, and/or the absence of breath sounds on the side of pneumothorax.
- Failure to discuss procedure with parent: Oftentimes, participants are focused on the task at hand, and do not maintain situational awareness of the parent. In this case, the parent should ask what is going on, and lead the team member to discuss the emergent procedure with the family.
- Failure to share mental model: Often, novice learners forget to recap for the team. An embedded participant serving as a team member may be helpful in prompting for a recap.
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