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Sneaky SF Dude
13 January 2004, 19:21
YMMV...this is not for the untrained, do not use or adopt without appropriate training and practice. You assume all risks for the use, mis-use, and/or abuse of this information! This is SERIOUS medicine and should be approached only by those with proven training, experience, and judgement.

Respiratory Distress, Asthma Attack, & Allergic Reaction In The Wilderness, Remote, & Disaster Setting

Purpose:
This protocol has been developed for use by appropriately trained individuals to aid in the recognition, management, and treatment of respiratory distress, asthma exacerbations, and allergic reactions. It is based on principles defined by the United States Department of Transportation, State of Nebraska Department of Health & Human Services, the Wilderness Medical Society, and the National Association of EMS Physicians.

Scope:
This protocol is limited to the use of XXXXX personnel and XXXXX Hospital medical care staff while working in wilderness, remote, or disaster settings where immediate medical care is not available. Isolation due to weather conditions, loss of transportation and communications, and/or loss of road access is included in this definition. It is not for use when transport times are short, routine systems and services are not impaired, and access to medical care is readily available.

Application & Use:
This protocol may be employed if the following conditions are met:
1. The patient is in a wilderness, remote, or disaster setting where medical care is not immediately available, as defined in “Scope” above.
2. Those using this protocol have been trained, tested, and approved by the XXXXX Medical Director, and will be re-certified every 6 months.
3. Every effort will be made to communicate with the Medical Director or receiving hospital medical control physician prior to initiating therapies given in this protocol, however if communication is not available therapy will be initiated and contact made as soon as is feasible.

Definitions:
Respiratory distress is defined as increased work of breathing, respiratory rates too fast or too slow to support the patient for more than a few minutes, and/or inadequate oxygen intake. Asthma exacerbations or “attacks” are defined as severe constriction of the airways and respiratory distress, often caused by allergic reactions, heavy exercise, or both.
Anaphylaxis and life threatening allergic reactions are defined as effects caused by toxin/allergen contact by any method or mechanism of exposure that produces shock and/or impaired circulatory, respiratory, neurologic, or metabolic bodily function to the extent that a patient’s health or life may be endangered.

General Principals:
1. Respiratory distress can develop from infection, cardiac failure, smoke or gas inhalation, asthma exacerbations, allergic reactions, and other causes. Allergic reactions may come from exposure to bites, stings, inhalation, ingestion, contact, or other mechanism. A specific source may not be identifiable. Treatment is initiated based on a patients signs and symptoms, not on the presence of an identified source of allergic reaction.
2. Early recognition & treatment may be essential to saving the patient’s life.
3. The triggering factor, toxin, or allergen may persist in the body longer than the therapy. Asthmatic reactions may also reoccur. Watch closely for reoccurring signs and symptoms and retreat as necessary
4. All patients requiring treatment are to be evacuated to the nearest medical facility

Signs & Symptoms:
Mild Distress - itching, shortness of breath but able to talk normally, metallic taste in mouth, minor rash or swelling, normal vital signs.
Moderate Distress - wheezing or stridor but able to talk in brief phrases or sentences, swelling, rash, hives, rapid heart rate, rapid & shallow respirations, tripod position.
Severe Distress – profound wheezing or stridor, unable to talk, a sense of doom, falling blood pressure, falling pulse, shock, loss of consciousness.

Treatment For All Patients With Respiratory Distress Of Any Source:
1. Perform CPR as needed, consistent with the SOP’s.

2. Offer calm reassurance & control to the patient.

3. Remove the patient from any source of respiratory irritation, such as smoke, fumes, & gases. Recall that high winds may place a large amount of dust and pollen in the air. For allergic reactions remove any insect stingers, plant oils, or other sources.

4. Secure the airway with patient positioning, nasal/oral airways, assisted ventilation, and intubation (Combi-Tube, direct, retrograde, cric, etc.) as needed. Intervene early!

5. Suction secretions as needed.

6. If available, give OXYGEN, high flow (8-15 liters/min.) for serious respiratory distress, smoke or carbon monoxide inhalation, or severe allergic reaction. For less serious patients low flow (2-6 liters/min.) may be adequate and will conserve your oxygen supply.

7. For all patients give ALBUTEROL (Proventil, Ventolin) inhaler 2 puffs every five minutes, or nebulizer 1 unit dose vial every 15 minutes, until improvement in respiratory distress is seen and then every 1 hour as needed. A routine treatment every 4-6 hours may be helpful in preventing re-occurrence. Recall that albuterol can produce mild tachycardia, tremors, and distress in some patients, but these are not serious in the short term. Do not withhold this medicine if they are in severe respiratory distress.

8. For patients in severe respiratory distress from any cause give the above plus:
EPINEPHRINE (Adrenaline) 0.3 ml into the muscle of the thigh or upper arm, or by auto-injector (Epi- Pen). For patients less than 80 pounds give 0.15 ml into the muscle of the thigh or the upper arm, or use the pediatric auto-injector (Epi-Pen Jr.). The Epinephrine may be repeated every 5 - 15 minutes as needed if worsening or not improving. Recall that epinephrine can cause significant tachycardia, tremors, and even chest pain if the patient has an underlying cardiac condition. Do not withhold this medicine if they are in severe respiratory distress. Consider intubation if the patient does not rapidly improve.

9. For any potential allergic reactions give the above plus: DIPHENHYDRAMINE (Benadryl) 50 mg oral or intra-muscular (IM) injection into upper arm every 6 hours for the first 24 hours. For patients less than 80 pounds give 25 mg. Recall that diphenhydramine can produce mild sedation and thickening of secretions, but these are not serious in the short term.

10. For patients in moderate or severe respiratory distress or allergic reactions give the above plus: METHYLPREDNISOLONE (Solu-Medrol) 125 mg intra-muscular (IM) injection into upper arm or buttocks. For patients less than 80 pounds give 60 mg intra-muscular (IM) injection into upper arm or buttocks. This may be repeated every 6 hours for the first 24 hours if needed. Recall that methylprednisolone can produce insomnia and agitation in some patients, but these are not serious in the short term.

11. For patients with symptoms of cardiac/congestive heart failure consider the use of FUROSIMIDE (Lasix) and other interventions as discussed in the cardiac & chest pain protocol.

12. For mild and moderate distress encourage ORAL FLUID intake if the patient is able to swallow and protect their airway. For patients in severe distress, if available, give NORMAL SALINE or RINGERS LACTATE 1000 cc’s either intra-venous or dermoclysis (under the skin) over one hour (IV) or two-three hours (dermoclysis), with additional fluids to be given per SOP as needed. For patients less than 80 pounds follow the fluid resuscitation SOP. Fluids are important to maintain an adequate intra-vascular volume and to thin pulmonary secretions.

13. Perform a complete assessment of the patient, evacuate immediately, treat any underlying causes such as infection, & monitor for reoccurrence of symptoms. Monitor SaO2 if possible. Make contact with medical control as soon as possible.

14. Common alternative acute acting beta agonists other than as above: Terbutaline, Metaproterenol, Levalbuterol, Pirbuterol, Combivent, Caffeine (any source)
Epinephrine alternative: Primatene Mist inhaler delivers 0.22 ml of Epi per squirt
Steroid alternatives: Prednisone, Solu-Cortef, Kenalog, many others
Antihistamine alternative: Chlorpheniramine, Clemastine, Hydroxyzine, Claritin, Allegra, Zyrtec, many others. H-1 blockers such as Zantac, Axid, Pepcid, Tagamet may be helpful also

15. In extended care situations recall that each episode of acute respiratory injury, such as infection, may make the patient more prone to such episodes in the future. Prevention is the key. Natural bronchodilators such as a caffeine containing drink several times a day, and inhalation of warm humid air may help.

sire24657
29 January 2004, 02:07
As an asthmatic, I used to have epi-pens. They have since expired, but my doc won't renew the prescription.

I love to do things in the outdoors, and I am worried that I might have a severe attack in the middle of BFE.

I usually have my albuterol w/ me; is there anything else you could recommend? Should I ask the doc again (the epi-pen was originally ordered because she thought I was allergic to bee stings (was stung by a scorpion once - hurt like hell, but my excitement was what triggered the attack)...

Thanks for any advice,

Sire24657

RIT_MEDIC
29 January 2004, 09:15
Benadryl 100mg

JD

BP
18 February 2004, 00:35
I would caution the use of Benadryl in someone with an acute asthma exacerbation.
You are certainly right in anaphylaxis (bee or scorpion sting), but not for asthma.

Just a blurb: "Diphenhydramine has an atropine like action and therefore should be used with caution in patients with a history of bronchial asthma," Benadryl will thicken the secretions in asthma and likely lead to worsening respiratory distress in an acute asthma exacerbation.

I would talk to your doc again.