Protocol 6 - Severe Asthma
This wilderness medical field protocol outlines the treatment of a severe asthma attack causing persistent respiratory distress not responding to the patient’s use of a rescue inhaler. This is a high-risk problem that can cause respiratory failure and death from respiratory arrest.
Early recognition and prompt treatment is essential. In fact, early recognition and prompt treatment (within 5 minutes); particularly in a wilderness setting, may actually be essential to saving a person’s life. Patients who experience a severe asthma attack may present with a combination of the following:
Shortness of Breath (>30 respirations per min)
Mental status changes (anxious, confused, combative, drowsy, etc.)
Inability to speak in sentences
Unable or unwilling to lie down
Sweaty
Recommended Treatment
If the patient is not responding to or is unable to properly use an MDI (metered dose inhaler), proceed to the following:
Inject 0.01 mg/kilogram (up to 0.5 mg) of 1 mg/ml solution of adrenaline intramuscularly (IM) into the lateral mid-thigh. A dose of 0.3 to 0.5 mg is appropriate for the average adult.
Maintain an open airway and position of comfort. Initiate either positive pressure ventilation (PPV) or cardiopulmonary resuscitation (CPR) as indicated.
Repeat adrenaline injections as soon as every 5 minutes if needed.
Prednisone 60 mg/day for an average adult.
Have the patient self-administer 6-10 puffs from the MDI/HFA. This may be repeated every 20 minutes for a total of three doses.
Evacuate to definitive care if safe to do so. Consider an advanced life support intercept en route (Advanced Life Support).
If evacuation is not possible, monitor carefully and repeat treatment per protocol as necessary.
NOTE: The preferred concentration of adrenaline for IM injection is 1 mg/1 ml. Although the lateral mid-thigh is preferred, an injection into the deltoid may be the only practical option.
Commercially available auto-injectors such as the EpiPen deliver either 0.3 mg or 0.5 mg as a standard adult dose or 0.15 mg or 0.1 mg for a smaller person (less than 55 lbs.; 25 kg), depending on body mass.
The auto-injector is the most user-friendly device, but also the most expensive. Adrenaline is also supplied in 1 ml ampules, and vials of various sizes, for a fraction of the cost. CWS graduates at the WEMT and WFR levels are trained in the use of syringes, needles, vials, and ampules for this purpose.
For patients weighing less than 55 lbs. (25kg), the doses are, epinephrine 0.01 mg/kg or the appropriate auto-injector and prednisone 1 mg/kg. Multiply the weight in pounds times 0.45 to get the weight in kilograms.
The organization may need a prescription from a medical advisor to obtain the injectable adrenaline, syringes, and prednisone used in the protocol. It is essential for prescribers and organizations to be familiar with state, provincial, or national regulations that may address the prescribing of medication and the acceptable means of injecting adrenaline.
