Life Threatening Asthma

What are the factors relating to Near Fatal Asthma?

I have written this article in response to a call we responded to a little while ago, which initially was given as a R2 DIB/Asthma (R2 = Red 2, the only higher category call is R1 Cardiac Arrest). We were second vehicle responding, a First Response Paramedic car was on scene first and the call had been upgraded to a Red 1 within seconds of the Paramedic arriving. Why? The patient was in cardiac arrest and a member of the public was performing (effective) CPR. By the time we arrived, some moments after the paramedic was on scene, return of spontaneous circulation (ROSC) had been achieved and together, we worked on management of the patient and eventual conveyance, as a ‘Blue Call’ (ie pre alert) to the nearest A&E.

This was a call that could have had a very different outcome. What if there was no member of public doing CPR? What if the person had been at home and had not been able to get to the phone? Many what-ifs come to mind, however, in the instance, someone stepped forward and saved the life of our patient.

So what exactly is ‘near fatal asthma’?

There are a number of ‘risk factors‘ which can lead to this occurring:

    Has the patient had a near fatal attack before?
    Previous hospital admissions for asthma in the past 12 months, and have these admissions required the administration of three of more classes of medication?
    Beta2 agonist?
    Non compliance with meds?
    Non attendance at asthma clinic/GP?
    Self discharge from hospital, following admission for asthma episode?
    And the list goes on…

So how would your patient appear?

Perhaps they would experience what would otherwise be a ‘normal’ asthma attack, and this progresses into a ‘life threatening asthma’ attack. This is typified by ONE or more of the following signs and symptoms:

    Decreased LOC (level of consciousness)
    Exhaustion (which may in itself lead to Sudden Cardiac Arrest)
    Silent Chest
    Poor respiratory effort
    PEF <33% best or predicted Sp02 <92% Pa02

Treatment plan:

If any of the above problems are present (classed as time critical):

    start correcting Airway and Breathing problems
    administer high levels of supplementary 02
    continuous SALBUTAMOL nebulisation unless clinically significant side effects occur
    administer ADRENALINE 1:1000IM only
    undertake a TIME CRITICAL transfer to nearest receiving hospital
    continue patient management en-route to hospital continually revisiting ABC’s
    provide a pre-alert call (CASMEET)
    be prepared to start CPR

Key Points to remember:

    Asthma is a common life threatening condition
    Its severity is often not recongnised
    Complete accurate PRF – with all drugs recorded
    Silent chest is a ‘pre-terminal’ sign

(JRCALC Clinical Practice Guidelines 2013)