In the ED, their vitals/exam are significant for tachycardia, increased respiratory effort and rate, inspiratory and expiratory wheezes heard throughout, and diminished sounds at the apices bilaterally. Concern for status asthmaticus with possible triggers including PNA, viral URI, and allergic reaction. Lower suspicion for PE as patient without pleuritic CP or LE signs of DVT including no edema/unilateral swelling/calf pain. Lower suspicion for primary cardiac etiology given EKG and lack of hypervolemia on exam. No history to suggest foreign body aspiration.
– Labs/Tests: VBG plus, CBC, CMP, PRO testing including Biofire. Consider blood cultures if concerned for pneumonia.
– Imaging: CXR***
– Treatments:
— Escalating respiratory support as indicated (NC -> NRB -> HFNC -> BiPAP -> Intubation)
— Stacked duonebs -> continuous albuterol 5 mg/mL (0.5%) at 5-20mg/hr
— Methylpred 125mg
— Magnesium 2-4g IV
— IVF/pain control/antiemetics as necessary
— Consider low dose fentanyl (25 mcg aliquots) OR droperidol (1.25 mg aliquots) OR precedex gtt OR ketamine (0.1 mg/kg bolus -> 0.5 mg/kg/hr gtt) if patient anxious/unable to tolerate BiPAP
— Consider terbutaline 0.25mg SQ, epinephrine 1-2mcg/kg/min gtt, heliox (to improve laminar flow) if refractory symptoms
— If requires intubation, use ketamine as induction agent (given provides some bronchodilatation), propofol/fentanyl for sedation, allow for permissive hypoxemia (SpO2 >90%) and permissive hypercapnia/acidosis to achieve decreased respiratory rate (8-12) that allows for prolonged time to expire, and increase I:E time (1:4-5) to similarly match respiratory mechanics.
— If still refractory despite above, consider VV ECMO
– Consults: None
– Dispo: Likely admission to ICU