ED Muskoka Physicians - Living the Dream

Peds Asthma simulation follow-up: November 24/25 2022

Hi Team –

We ran a simulation of a pediatric asthma case in both ER departments this week (Dr. Sawula led in Bracebridge and Dr. Jewell in Huntsville) and wanted to share a few learning points that came out of the case. Thanks to everyone who participated at both sites. There was some great discussion! The following info has been circulated to our nursing team at both sites as well.

This was a case of a 2 year old boy presenting with a severe asthma exacerbation, unresponsive to usual initial therapies (Ventolin/Atrovent/Steroids) i.e. Status Asthmaticus, progressing towards respiratory failure.

Learning points:

  1. PRAM Score – a really useful scoring tool to help quantify severity, track progress over time in ER, and create a common language to speak with our pediatricians. We do not currently use a formal asthma clinical pathway or orderset in our ER, however, we should be ensuring our management reflects this standard of care. A copy of the PRAM scoring tool is posted on the wall in Triage in Huntsville
  2. IV Magnesium Sulfate – is a 3rd line agent (after Ventolin/Atrovent/Steroids) – consider using if moderate to severe score and not improving after 1st hour of treatment. Dose is 25-50mg/kg/dose (max 2g) over 20-30 min, watch for hypotension and bradycardia. Must be on continuous cardiac monitoring.
  3. IV Ventolin (Salbutamol) – option in severe cases unresponsive to above therapies (including no response to continuous nebulized Ventolin) and possibly progressing towards respiratory failure. Ottawa Manual has a resource for how to dilute/administer this uncommonly used drug. YES we have it available. Sick Kids PICU doc should be contacted if this is being considered as this is an ICU-level therapy but can get started while waiting for transfer team. Generally Sick Kids recommends NO loading dose, but starting maintenance dose at 1-2mcg/kg/min and titrating q10min up to 5mcg/kg/min (Max 20mcg/min)
  4. Oxygenation/Ventilation – for impending respiratory failure, consider Heated/Humidified High Flow Nasal Cannulae. We have nasal prongs and flow rates appropriate for smallest kids so this is a good option. RT can set this up for us. We do NOT have masks small enough to do BiPap/CPAP on kids <20kg. We do have neonatal CPAP/PPV via the Neopuff T-piece resuscitator, which can technically work up to 10kg, but this does require hands on ventilation. **There is a high risk of mortality with intubation (high risk pneumothorax, impaired venous return, CV collapse… all sorts of badness), so last resort of management.

See this SickKids Webinar for more education on managing a severe asthma exacerbation pending transfer to a tertiary care hospital

Hope these brief summaries after simulations help keep us on the same page. As always, if there are any topics you want reviewed please let Heather, Emma or I know. Stay tuned for December dates!


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