Case summary:

An ALS crew was dispatched to a middle-aged man with reported difficulty breathing.  Crew was waved down by a bystander who said that patient had a history of COPD or asthma and had complained of rapidly progressing difficulty breathing.  The patient walked outside and began to fall but was caught be a bystander and placed on the ground.  Crew found the patient unresponsive, with a weak pulse in the 40s and shallow breathing.  The crew positioned the airway and provided BVM ventilations with 15 LPM of O2.  The checked a sat and it was in the 30s.  Pupils were equal and not constricted.  Patient was extricated to the rig since he was already on the porch.  The crew noted that the patient was difficult to bag and had diminished breath sounds bilaterally.  Given history of bronchospasm, they gave 0.5mg IM epi to help improve air movement.  The crew was able to get a complete set of vitals at this time as well

Vitals: BP 152/107,  HR 129,  RR 20 (via BVM),  Sat 97% 15L,  glucose 154, ETCO2 56 mmHg

The crew obtained a 12-lead which did not show evidence of STEMI.  The crew also obtained an IV and administered steroids and then started running aerosolized bronchodilators through the BVM.  The patient slowly became more arousable and began breathing on his own.  He became completely conscious and reports a history of COPD and having been intubated in the past for COPD exacerbations.  He denied any other symptoms besides shortness of breath.  Patient was given breathing treatments continuously throughout his transport as well as an infusion of magnesium.  Patient was transported to the nearby hospital and his vitals before arrival were:

Vitals: BP 138/82,  HR 118,  RR 16,  Sat 99% on O2, ETCO2 31 mmHg

Highlights of the case:

Resuscitation before extrication.

Most of our critical patients are “stay and play” patients.  This means that the best thing we can do for them is to start our EMS care immediately prior to extrication.  The reason for this is that often these patients are at risk of (or are already accruing) irreversible organ damage and/or hemodynamic collapse.  If we start our care right away, we might be able to intervene before this occurs.  The exception to this rule is our trauma patients where we instead prioritize transport.  This crew found an unresponsive patient in respiratory failure.  The crew correctly repositioned the patient’s airway and provided BVM ventilations with 100% O2.  This patient almost certainly would have gone into cardiac arrest if this treatment was delayed.  The crew’s quick initiation of care is what saved his life.  Given the patient was right outside the ambulance, it was very reasonable to quickly extricate once they were able to stabilize the patient with BVM.  If the extrication were to have been longer or more complicated, complete resuscitation should have occurred before any attempt to extricate. 

Patients with respiratory distress often require every treatment at our disposal.

Patients with respiratory distress often progress rapidly to respiratory failure or respiratory arrest.  For this reason, why often want to quickly determine what the most likely underlying cause is and initiate the appropriate treatment algorithm.  If it is unclear what the underlying cause is, it is often OK to treat for both at the same time since patients might have multiple simultaneous causes for their respiratory distress and need to be treated for each.  The two that we most often think about are COPD/asthma and pulmonary edema from congestive heart failure (as well as other causes of pulmonary edema).  It is important to remember that there are other causes of respiratory distress such as myocardial infarction, pulmonary embolism as well as many others.  The good news is that many of the treatments for COPD will not make a pulmonary edema patient worse and the same is true for the treatments for COPD/asthma.  We should use the treatment algorithm that seems to apply the most first, but be ready to pivot to the other if repeat assessment or new history indicates as much.  For COPD/asthma, we want to lead with the most important thing which is inhaled bronchodilators.  There is no limit to the max number of treatments and if the patient is sick enough, he or she should receive not stop treatments.  It is also important to note that these treatments can be given via BVM or CPAP, so use of these treatments do not negate the use of bronchodilators.  For concern for severe asthma that fails to improve with bronchodilators, we can consider IM epinephrine, but this can increase risk of cardiac ischemia in elderly patients, especially those with underlying cardiac disease.  Any patient treated by EMS for COPD or asthma should receive steroids, even if the patient feels better or is refusing transport.  This is because the steroids will decrease the risk of the patient re-developing bronchospasm in a few hours since this treats the underlying inflation that plays a role in these diseases.  The last thing we should consider is treating with magnesium since this can help and is unlikely to harm most patients.  The crew in this case correctly identified that the patient was presenting with severe bronchospasm and then treated the patient with each modality they had for this disease process.  The only thing they could have done better would have been to treat with the bronchodilator right from the start, but other than this, they did exceptionally well.

Treat for the most likely issue but consider other causes too.

This patient presented with respiratory failure that was most likely from bronchospasm.  The crew correctly treated for this etiology, but they also evaluated for other potential causes since patients can have multiple simultaneous things going on at the same time.  The crew assessed the patient’s pupils to evaluated for opioid toxicity.  The crew checked a glucose to make sure the patient was not hypoglycemic.  The crew also checked a 12-lead EKG to look for signs of STEMI since STEMI can cause pulmonary edema from blowing a valve or causing cardiogenic shock.  This was all fantastic care since doing these things ensures they will not miss a critical problem that we need to treat for immediately.