Wilderness and Rescue Medicine 8th Edition

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Section III: Critical System Problems and Treatment

These do not act fast enough to help in an acute attack. Encourage the patient to inhale as deeply as possible while the inhaler is discharged into the mouth. The efficiency of the inhaler can be improved using a spacer to contain the vapors while the patient inhales. This is simply a plastic tube with the inhaler on one end and the patient on the other. You can improvise a spacer by using a plastic water bottle with the end cut off.

times over the next hour. Each 6 to 10 puff dose is roughly equivalent to a nebulizer treatment in a clinic or hospital. If evacuation is likely to take more than 3 hours, add a 10 mg dose of dexamethasone or a dose of prednisone at 1 mg/kg given by mouth (40–60 mg for an adult, 20 mg for a child). As with anaphy- laxis, this will reduce lower airway inflammation and the chance of another attack.

General Principles

Asthma Treatment WILDERNESS PROTOCOL Respiratory distress not responding to the inhaler: • PROP • Epinephrine o Inject 0.3mg (0.3ml) by intramuscular injection (IM) into lateral mid-thigh (or deltoid if the thigh is inaccessible) . • β -agonist rescue inhaler (6 – 10 puffs up to 3x over the next hour), then as prescribed. • Steroid (pick one): o Dexamethasone 10mg single dose. o Prednisone 60 mg per day. • Evacuation

General Principles

5

Asthma

Treatment: • PROP

• Rescue inhaler (albuterol, salbutamol) • Emergency evacuation or ALS support if not responding to the inhaler

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Low Risk

High Risk

Rescue inhaler with water bottle spacer

© 2018 WMA

© 2018 WMA

Risk Versus Benefit This protocol is for use in severe respiratory dis- tress leading to respiratory failure caused by lower airway constriction in a known asthmatic. It is safe, effective, and carries little risk compared to the problems associated with inadequate oxygen- ation. It is an important life-saving skill for both basic and advanced practitioners operating in remote areas.

It is safe to make several attempts to abort the asthma attack with an inhaler. However, do not delay moving to the next step if it is apparent that the patient cannot effectively inhale the medica- tion. If use of the inhaler fails to reduce symptoms within a few minutes, the patient will need an injection of epinephrine. Before medications like albuterol became avail- able, epinephrine was a first-line treatment for an asthma attack. It is the same medication used for the emergency treatment of anaphylaxis. It is given in the same concentration and dose by intramuscular injection (see the allergy and ana- phylaxis chapter). The Wilderness Protocol for severe asthma calls for 0.3 mg injected into the lateral aspect of the thigh. For children, the dose is 0.01 mg per kilogram up to 0.3 mg. The patient will usu- ally feel better within a few minutes. One dose of epinephrine may completely abort the asthma attack, but a second dose may be given within as little as 5 minutes if needed. Once symptoms improve, the patient should self-administer their own inhaler at a dose of 6 to 10 puffs up to three

General Principles

Severe Asthma Wilderness Perspective

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High-Risk Problem:

• Persistent abnormal mental status • Incomplete response to treatment • HFA/MDI continues to be ineffective • The patient is getting worse

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© 2018 WMA

The disease itself can become a significant prob- lemwhen the triggers cannot be avoided. Asthma