Clinical Treatment of a 4 year old with Severe Asthma

PDA Clinician @ Large
Grant E. Fraser, MD

At 4:30 am, a 4 year old, 45 lb boy presented with his mother to the ER with complaint of
difficulty breathing. The ER Triage nurse requested my immediate attention for this
child. He had a history of asthma induced by colds when he was younger, but hadn't
been on any recent therapy or had trouble in the prior 2 years.

During the last 24 hours, he had developed increased difficulty with breathing, which to
the child's mother appeared similar to his previous problems with asthma. He had never
been admitted to a hospital for asthma exacerbation.

The triage documented a respiratory rate of 60, HR 150, O2 Sat 92% on room air, temp

His exam was that of a child in respiratory distress with diffusely diminished air
movement, increased work of breathing and barely audible tight inspiratory and
expiratory wheezes. It was unclear how much reserve this child had left, but the concern
was high enough to have immediate Respiratory Therapy attention with O2 blow by, a
Unit Dose of Albuterol and Atrovent with plans for continuous albuterol thereafter
depending upon response.

I requested the nurses establish IV access. This promptly occurred and an IV fluid bolus
of LR was started with orders for this to be followed with D5 ½ NS at 1.5 times
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Solumedrol 2 mg/kg was administered by IV bolus and a bolus of IV Magnesium Sulfate was ordered [Screens 1, 6 & 5].
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Blood was drawn from the IV line for CBC, BMP and bedside glucometer. A portable chest Xray was ordered.

The principles here are:

1. A child with this presentation may deteriorate unpredictably and should this occur; an
IV line is a good thing to have.
2. Children with asthma exacerbations are often dehydrated and improve with fluid
3. Children under any stress may become hypoglycemic and bedside glucometer is
indicated (which in this case was 109);.
4. Steroids should be administered.
5. IV Magnesium sulfate may have benefit especially in severe cases through mechanism
of smooth muscle relaxation.
6. Prepare for the worst; it just might happen.

Half way into the nebulized treatment, the child appeared panicked, gasping for air and
appeared increasingly confused.

My assessment was that of a severe respiratory compromise with impending respiratory
arrest, likely due to asthma exacerbation.

This child had at this point only been in the ER for 7 minutes, so much of the preparation
was ongoing. He had an IV, the bolus of LR was running, the steroids had been
administered and the IV bolus of magnesium was being prepared for infusion.

I immediately called for 1:1,000 epinephrine 0.2 mg subcutaneously and prepared the
airway equipment.
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Doses of Midazolam and Succinylcholine with Atropine were drawn.
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A 5.5 cuffed ETT was readied and 100% oxygen was administered in anticipation of intubation.

The hope was that the subcutaneous epinephrine would stabilize matters as this is often
rapidly effective in critical cases. Unfortunately there wasn’t the reserve needed as
within 60 seconds of giving the epinephrine, the child had gone to moving essentially no
air and O2 sat rapidly declining to 80%.

Respiratory therapy was present, the ETT and laryngoscope along with CO2 monitor had
been readied. Pediatric BVM with 100% O2 was utilized while final preparations were
made. Atropine, Midazolam, and Succinylcholine were given in rapid succession and
endotracheal intubation with a 5.5 cuffed ETT was performed. Clinical, ET CO2 and
radiographic assessment showed excellent ETT placement with normal appearing lung

Other therapies of magnesium infusion and fluids were continued. O2 saturation
improved and this child's condition stabilized. Continuing sedation with midazolam was
utilized as needed and the child was stable with transport arranged to All Children's
Hospital, our regional pediatric specialty hospital.