A 14 year old girl is called through by paramedics with sats of 89% in air and wheeze. They have given a 5mg Salbutamol nebuliser with little improvement. ETA 5 minutes.
— Known poorly controlled asthmatic. Previous HDU admissions for wheeze.

Observations

A – Patent

B – RR 30, Sats 91% on nebuliser, 89% in air. Recessions noted

C – HR 130, CRT <2sec, BP 130/80

D – Alert

E – Temperature 37.4°C. 

Clinical Findings

  • Global wheeze with reduced air entry

  • Unable to speak due to breathlessness

  • Looking tired

Why We Simulated

1 in 11 children in the UK has asthma, making it the most common long term medical condition. Acute asthma exacerbations are also commonly seen in the paediatric ED, with on average across the UK 1 child admitted to hospital every 20 minutes.[1] As is true for all emergency presentations, there is a wide spectrum of severity at presentation, ranging from the usually well controlled asthmatic with a mild exacerbation to those who present in extremis with impending respiratory failure.

(Fig. 1) Difficulty in Breathing Grab Box

In this scenario, a 'Red Call' was made to the ED team, allowing for advanced planning in terms of team and equipment preparation. Our paediatric Difficulty in Breathing grab box (see Fig. 1) can be found both in Resus and the Paediatric ED. It contains nebulisers and steroids, speeding up the sourcing and initiation of these life saving drugs in the emergency situation.

Initial assessment of asthma exacerbation severity is identical to that in adults with a history of poor control and previous high dependency or intensive care admissions making the patient higher risk. In situations where the assessment fits with a severe grading, it is a good idea to plan ahead by applying Ametop early in anticipation of the possibility of lV Salbutamol administration.

Management of the unwell asthmatic patient requires regular reassessment of the response to bronchodilators. Most children dislike nebulisers and involving a play specialist can make a real difference in keeping a child and their parents calm, distracted and therefore more likely to receive effective treatment during this stage.

Some of the asthmatic patients who attend the ED are stable enough to be discharged home after a period of treatment and observation. Within our departmental Standard Operating Procedure for the Management of Wheeze and Asthma in Children, we have safe discharge planning recommendations which include giving the patient a written asthma management plan; safety netting advice for when to seek emergency medical advice if further symptoms occur; and asking the parents to book a GP review appointment within 2 days time to ensure the acute symptoms are improving.

References:

  1. Asthma UK: Asthma Facts and Statistics

Further Reading:

Learning Outcomes

  1. If you have a pre-alert for an asthmatic patient, make good use of this time by sourcing the Difficulty in Breathing grab box which can be found in the Paediatric ED and in Resus.

  2. A normal or raised pC02 on a blood gas in an acute asthmatic patient is concerning and a sign of impending respiratory failure.

  3. Paediatric patients started on IV Salbutamol will need an HDU or PICU bed.

Positive Feedback

  • Appropriate targeted history taking allowed the team to recognise this girl was high risk in terms of poor asthmatic control and treatment compliance, with previous HDU admissions.

  • All drugs were appropriately prescribed and administered.

  • Using the SBAR approach enabled an effective handover to the on call paediatric registrar.

Edit & Peer Review by Gareth Lewis

Comment