Protocol 2: Asthma

Basic Life Support Protocol

Asthma is an inflammatory disease of the airways which results in more than 450,000 hospital admissions and 5,000 fatalities a year. Every patient with asthma is at risk for a severe, acute exacerbation that requires aggressive management. The newly developed Guidelines for the Diagnosis and Management of Asthma: Expert Panel Report II, published in 1997 includes recommendations for all phases of asthma management. Early recognition and prompt treatment, particularly in the wilderness setting may be essential to preserve life.

*An asthma exacerbation is indicated by the presence of several, but not necessarily all of the parameters listed. These parameters serve as guides.

Patients who have progressed to severe asthma experience a combination of the following:

•	Shortness of Breath (>30 respirations /min)
•	Mental status changes (anxious, confused, combative, drowsy, etc.)
•	Inability to speak in complete sentences
•	Diaphoretic (sweaty)
•	Unable or unwilling to lie down

If the patient is not responding to or is unable to properly use an MDI (metered dose inhaler), proceed to the following:

1.	Start supplemental oxygen if available: 4-6L/min by nasal canula or 10-15 L/min with a NRB (non-rebreather mask).
2.	Inject 0.01 mg/kilogram up to 0.3 mg of 1:1000 solution of epinephrine into the lateral aspect of the deltoid, or the anterior aspect of the thigh (either subcutaneous or intramuscular).; if clinically indicated, repeat dose every 5 minutes for two additional doses.*
3.	Administer Prednisone at 40 - 60 mg (or equivalent dose of an oral corticosteroid).
4.	Initiate assisted ventilations (PPV) if breathing becomes ineffective (gasping or shallow respirations or if AVPU or less). Maintain a rate of 8-10 bpm.
5.	Once able to do so have patient self-administer 4-6 puffs from the MDI. Use a spacer if available. May repeat every 20 minutes as needed.
6.	Evacuate the patient.

*There is 1 mg of epinephrine in 1 ml of epinephrine 1/1000; there is 0.3 mg in 0.3 ml of 1/1000. Pre-loaded commercially available injectors deliver either 0.3 mg (standard adult dose) or 0.15 mg (standard pediatric dose). If the person weighs less than 66 lbs (30 kg), the doses are: epinephrine is 0.01 mg/kg; prednisone is 1 - 2 mg/kg. When using lbs, multiply the weight times 0.45 to get the weight/mass in kilograms.

Advanced Life Support Protocol

If patients progress to respiratory failure and develop any combination of the following:

•	Gasping or shallow respirations or retractions between ribs on inspiration
•	AVPU of 'Verbal' or less
•	O2 sats of <90% on supplemental oxygen

Initiate advanced airway management. Maintain a rate of 10-15bpm.

•	Poor lung compliance may be present (as evidenced by difficulty getting air in). Providing increased flow/pressure may be necessary to ventilate the patient. Allow adequate time for exhalation.
•	The increased ventilatory pressures can lead to barotrauma (i.e., simple or tension pneumothorax). Monitor carefully. If the following signs or symptoms occur; new absence of lung sounds, and clinical deterioration (i.e., decreased perfusion, decreased O2 sats, decreased mental status), initiate a chest decompression using the standard technique.

Continue beta-agonist inhaler agents through the ET tube if possible.

Continue with the administration of epinephrine as noted above.

Contributing factors such as cold temperatures, stress, and exercise should be controlled as much as possible.

These protocols were written by Jeffrey Isaac, PA-C (of Wilderness Medical Associates International) and have been edited and authorized by Kathryn Vaughn, MD & Clifton Castleman, WEMT, for use by Center for Wilderness Safety.

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