CCS Case: Acute Asthma Exacerbation

Case: Acute Asthma Exacerbation

Clinical Setup

• Presentation: 24-year-old female with known asthma presenting with 1 day of worsening wheezing, dyspnea, and cough unrelieved by home albuterol. Speaks in short phrases, SpO2 90% on room air, peak flow 40% of personal best.
• Location: Emergency Department.

Optimal Order Pathway

1. Immediate Orders (Minute 0–1):
   • Pulse oximetry, continuous cardiac monitoring.
   • IV access, Normal saline 0.9% IV @ 75 mL/hr.
   • Oxygen via nasal cannula, titrate to SpO2 > 92%.
2. Focused Exam (Minute 1–2):
   • Lung exam (wheezing, air movement, accessory muscle use), Heart exam (tachycardia).
3. Diagnostics (Minute 2–4):
   • Peak expiratory flow rate (PEFR) stat.
   • ABG stat, CBC, BMP, CXR portable AP (rule out pneumonia/pneumothorax).
4. Therapeutics (Minute 4–12):
   • Albuterol + Ipratropium nebulized stat, repeat q20min x3.
   • Methylprednisolone IV stat (or Prednisone PO) — do not delay steroids.
   • Magnesium sulfate IV if severe/refractory exacerbation.
   • Advance clock 15–30 min after each albuterol round; repeat PEFR and lung exam to document improvement.
5. Disposition (Minute 12–18):
   • If improved (PEFR > 70%, SpO2 normal, speaking full sentences): discharge with Prednisone taper, albuterol inhaler, inhaled corticosteroid, spacer teaching.
   • If poor response: admit to ward; transfer to ICU if altered mental status, PaCO2 rising, or impending respiratory failure (prepare for intubation).
6. Final 2 Minutes:
   • Counsel on inhaler technique, trigger avoidance, smoking cessation, written asthma action plan.
   • Schedule primary care/pulmonology follow-up within 1 week.