What Is Asthma Attack

It is a deterioration of the baseline asthma control leading to acute wheeze, shortness of breath and dyspnoea.

What Causes Asthma Attack

• Upper respiratory tract infections (especially viral).
• Shortage of asthma drugs.
• Exposure to triggers (cold, dust, Smoke, etc)
• Stress

Signs and Symptoms Of Asthma Attack

• Wheezing
• Dyspnoea
• Mucus secretions
• Cough
• Chest tightness
• Quiet chest and decreased oxygen saturation (severe signs)

Complications Of Asthma Attack

• Pneumothorax
  Status asthmatics: an intractable asthmatic crisis with severe
  bronchospasm. It is managed by first evaluating ABC, with
  100% oxygen, salbutamol 0.5mg/hr IV, hydrocortisone 200mg
  IV bolus; if not responding give adrenaline 0.1mg/ IV bolus and
  magnesium sulphate 2g IV over 20min; If still not responding
  consider intubation and mechanical ventilation under sedation
  with ketamine12mg/kg IV
• Investigations
  FBC
  Blood gases
  CXR
• Do not give sedatives or aminophylline. Give anticholinergic such as ipratropium bromide in case of increased respiratory secretions. Monitor parameters indicating severity.

How To Treat Asthma Attack

Start treatment immediately

• Semi-sitting position O2 to keep saturation above 90%
• Short acting Beta 2 agonist nebulisation ( eg salbutamol 5 mg in 5 ml of normal saline over 10 minutes repeated ½ hour later).
• Hydrocortisone 100 mg IV every 6 hrs
  Assess the need of ventilation according to the response to the therapy
• Avoidance of the triggering agent if known.
• Patient education on medication and other strategies

Recommendations

Refer to tertiary level all cases with failure of above therapy of
acute asthma, development of status asthmatics. Also, contact your health provider.

Shock

Definition Of Shock

Shock is a syndrome characterized by decreased perfusion
of the tissues in the body which if prolonged leads to irreversible multiple organ failure.

Classification Of Shock

• Hypovolemic
• Cardiogenic
• Septic
• Anaphylactic

Complications Of Shock

• Renal Failure
• Hepatic Failure
• Metabolic Acidosis
• Coma
• Death

Hypovolemic Shock

Definition Of Hypovolemic Shock

This is due to loss of intravascular fluid volume (blood and/
or fluid loss).

What Is Hypovolemic Shock

• Excessive haemorrhage ( e.g. trauma, internal bleeding, such as in the gastrointestinal tract)
• Excessive fluid loss (eg. diarrhoea, vomiting, severe burns)
• Intestinal obstruction (mechanical or paralytic ileus)

Symptoms Of Hypovolemic Shock

• Fainting
• Palpitations
• Sweating (cold sweat)
• Restlessness
• Clouding of consciousness

Signs Of Hypovolemic Shock

• Pallor
• Cold extremities
• Tachycardia
• Hypotension: Systolic BP <90 mmHg
• Temperature is subnormal (less than 35°C)

Investigations

• FBC
• Serum urea , creatinine and electrolytes
• Blood sugar
• Group and crossmatch blood
• Blood gas analysis if possible
• Blood cultures

Management

• Non pharmaceutic
• Control obvious bleeding with direct pressur
• Insert one or two large bore IV catheters for rapid IV
  infusion
• Urinary catheter
  Initial volume resuscitation
• Raise drip stand or squeeze bag to increase infusion rate:
  Give colloids and/or crystalloids e.g. Sodium Chloride 0.9%.
  Aim to give 70 ml/kg body weight
• Monitor blood pressure, pulse and clinical response: Target a mean arterial pressure ≥ 65mmHg and urine output > 30ml/hr
• Most patients will respond to the initial fluid bolus
• If they respond initially and subsequently deteriorate, there
  may be an ongoing occult haemorrhage
• Consider blood transfusion (if haemorrhage is >25% of
  total blood volume)
• Fluid should be given quickly and slowed only when BP
  rises and urine flow is adequate
• Give Oxygen 6 L/min via nasal or facial masks if indicated
• Continue to monitor BP, pulse and urine output.

Recommendations

• Refer to ICU if needed.
• Refer for surgical intervention if indicated.
• Consult your health provider.

Cariogenic Shock

What Is Cariogenic Shock

This is advanced cardiac failure with inadequate peripheral
tissue perfusion.

Hemodynamic criteria are :

• Sustained hypotension for at least 30min( SBP 90mmHg)
• Low cardiac index( <2.2 l/min/m2)
• Elevated capillary wedge pressure( >15mmHg)

What Causes Cariogenic Shock

• Valvular Heart Disease
• Myocardial Infarction (Right or Left)
• Pericardial Tamponade
  Myocarditis.
• Hypertensive Obstructive Cardiomyopathy.
• End stage cardiomyopathy.
• Myocardial contusion.

Signs and Symptoms Of Cariogenic Shock

• BP less than 90mmHg systolic Weak or undetectable pulse
• Cold extremities
• Peripheral cyanosis
• Poor urine output
• Pulmonary signs (Crepitations, Dyspnoea)
• Raised JVP

Investigations

• FBC
• Serum urea, creatinine and electrolytes
• Cardiac Enzymes (LDH, Troponin, Creatinine Kinase)
  CXR

• ECG
  Echocardiography

Management

Non-Pharmaceutical

• Oxygen to keep saturation >90%
• Large bore IV cannula
• IV fluid bolus (if predominant right heart failure).
• Urinary Catheter

Pharmaceutical

• Diuretics if predominant left heart failure and pulmonary
  congestion (avoid otherwise): Frusemide eg 40mg IV stat
  and monitor response.
• Management of underlying cause
  →Ischaemia: Aspirin 100mg po stat, Morphine 210mg IV/IM for pain,
  Glyceryl Trinitrite (if BP permits, contraindicated in hypotension), Thrombilysis
  →For Pericardial Tamponade: pericardiocentesis

Recommendation

Refer to ICU or a tertiary centre if the patients with cardiogenic shock are not responding to above measures.