This is Part II of my discussion with Michael Perlmutter on asthma and COPD management. In this episode we discuss interventions used for advanced/severe asthma exacerbations including magnesium, epinephrine, ketamine, non-invasive positive pressure ventilation, and advanced airway management.

Facebook: https://www.facebook.com/paramedicpractitioner/
Instagram: @paramedicpractitioner
Email: amerelman@gmail.com
Twitter: @amerelman


Image: PulmCrit

References and Further Reading
UpToDatehttps://emedicine.medscape.com/article/296301-overview
https://canadiem.org/management-of-severe-asthma/
http://www.emdocs.net/critical-asthma-patient-pearlspitfalls-of-management/
https://rebelem.com/rebelcast-crashing-asthmatic/
https://emcrit.org/ibcc/asthma/
https://asthma.net/treatment/prevention/
https://www.jems.com/2018/04/01/a-modern-approach-to-basic-airway-management/
https://onlinelibrary.wiley.com/doi/full/10.1111/j.1742-6723.2009.01195.x
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6157154/
https://err.ersjournals.com/content/22/129/227.full
https://www.ncbi.nlm.nih.gov/books/NBK430901/
https://www.ncbi.nlm.nih.gov/pubmed/11406055
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2743582/
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6434661/
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3169834/
https://www.ncbi.nlm.nih.gov/pubmed/23235634
https://www.ncbi.nlm.nih.gov/pubmed/22479740
https://www.ncbi.nlm.nih.gov/pubmed/26033128
https://www.ncbi.nlm.nih.gov/pubmed/25447559
https://www.ncbi.nlm.nih.gov/pubmed/27289336
https://www.ncbi.nlm.nih.gov/pubmed/18922662
https://www.ncbi.nlm.nih.gov/pubmed/28754601
https://www.ncbi.nlm.nih.gov/pubmed/24865567
https://www.ncbi.nlm.nih.gov/pubmed/24731521
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3777369/
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6036522/

In this two-part series I discuss asthma and COPD. These diseases are complex and have a spectrum of severity and presentation. The sickest of these patients require prompt, aggressive care to prevent further deterioration so a thorough understanding of the disease is essential. Michael Perlmutter, flight/critical care paramedic and medical student, joins me for a great conversation on prehospital management of these diseases. This is Part I which covers pathophysiology, diagnosis, and early management. Part II will be released in a couple weeks and will cover treatments used in our more critical patients and advanced stages of exacerbations. As always, please follow us on our various social media accounts and let me know if you have any questions, feedback, or personal experiences to share.


Note: in the podcast at one point I say ipratropium and tiotropium are muscarinics but they are muscarinic antagonists.


Facebook: https://www.facebook.com/paramedicpractitioner/
Instagram: @paramedicpractitioner
Email: amerelman@gmail.com
Twitter: @amerelman

Below are some quick guides to home management of asthma and COPD. The treatment approaches between the two diseases vary. One of the biggest differences is that asthma patients are started on inhaled steroids relatively early in their progression but if you see a patient with COPD on an inhaled steroid, they are likely late in their disease process. By looking at a patient’s home medications you can infer some information about the severity and pathophysiology of their underlying disease.

Image: PulmCrit

References:

References
UpToDate
https://emedicine.medscape.com/article/296301-overview
https://canadiem.org/management-of-severe-asthma/
http://www.emdocs.net/critical-asthma-patient-pearlspitfalls-of-management/
https://rebelem.com/rebelcast-crashing-asthmatic/
https://emcrit.org/ibcc/asthma/
https://asthma.net/treatment/prevention/
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6157154/
https://www.ncbi.nlm.nih.gov/books/NBK430901/
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6434661/
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3169834/
https://www.ncbi.nlm.nih.gov/pubmed/23235634
https://www.ncbi.nlm.nih.gov/pubmed/22479740

On this quick episode I discuss hyperkalemia, a life-threatening condition commonly missed by out-of-hospital providers. It is essential to recognize the signs and symptoms of hyperkalemia as these patients may require prompt treatment to prevent fatal dysrhythmias.

References:

    http://hqmeded-ecg.blogspot.com/search/label/hyperkalemia
    https://emcrit.org/ibcc/hyperkalemia/
    Durfey N, Lehnhof B, Bergeson A, et al. Severe Hyperkalemia: Can the Electrocardiogram Risk Stratify for Short-term Adverse Events?. West J Emerg Med. 2017;18(5):963–971. doi:10.5811/westjem.2017.6.33033
    Lehnhardt A, Kemper MJ. Pathogenesis, diagnosis and management of hyperkalemia. Pediatr Nephrol. 2011;26(3):377–384. doi:10.1007/s00467-010-1699-3
    Ryuge A, Nomura A, Shimizu H, Fujita Y. Warning: The ECG May Be Normal in Severe Hyperkalemia. Intern Med. 2017;56(16):2243–2244. doi:10.2169/internalmedicine.6895-15

(ECGs from Smith’s ECG Blog http://hqmeded-ecg.blogspot.com)

Subtle hyperkalemia indicated by peaked T-waves and ST segment flattening in V3-V5
Hyperkalemia indicated primarily by peaked T-waves in V2-V4
Wide QRS and significantly peaked T-waves indicating hyperkalemia
Substantially widened QRS with sine wave morphology indicating severe hyperkalemia

Severe Crashing Acute Pulmonary Edema (SCAPE) is a life threatening complication of heart failure. In this episode, I discuss the pathophysiology and modern treatment modalities with flight paramedic and medical student Michael Perlmutter.

References

    Agrawal N, Kumar A, Aggarwal P, Jamshed N. Sympathetic crashing acute pulmonary edema. Indian J Crit Care Med. 2016;20(12):719–723. doi:10.4103/0972-5229.195710
    Hsieh YT, Lee TY, Kao JS, Hsu HL, Chong CF. Treating acute hypertensive cardiogenic pulmonary edema with high-dose nitroglycerin. Turk J Emerg Med. 2018;18(1):34–36. Published 2018 Feb 2. doi:10.1016/j.tjem.2018.01.004
    Levy P, Compton S, Welch R, Delgado G, Jennett A, Penugonda N, Dunne R, Zalenski R. Ann Emerg Med. 2007 Aug;50(2):144-52. Epub 2007 May 23
    Paone S, Clarkson L, Sin B, Punnapuzha S. Am J Emerg Med. 2018 Aug;36(8):1526.e5-1526.e7. doi: 10.1016/j.ajem.2018.05.013. Epub 2018 May 10.
    Scott Weingart. EMCrit Podcast 1 – Sympathetic Crashing Acute Pulmonary Edema (SCAPE). EMCrit Blog. Published on April 25, 2009. Accessed on July 10th 2019. Available at https://emcrit.org/emcrit/scape/
    IMAGE 2 – Pathophysiology of heart failure, Image from CORE EM
    IMAGE 3 – Spiral of death in heart failure, Image from CrashingPatient.net