Bronchial Asthma Case

A 6-year-old girl with a history of asthma presents to ED with

difficulty breathing. She has had several days of dry cough,
rhinorrhea, and high-grade fevers. Her mother reports that she
developed rapid breathing late last night and needed multiple puffs
from her albuterol metered-dose inhaler. The inhaler helped her
breathe more comfortably at first, but now it seems to have little
effect. For the last few hours, her symptoms have worsened
considerably to the point where she can hardly speak. The mother
briefly mentions that her daughter has had many ED visits for
asthma, 2 lifetime admissions, but no intubations or admissions to
the ICU. She uses only albuterol at home, as needed. Her doctor
prescribed an inhaled corticosteroid that was to be used daily, but
she ran out a few weeks ago.

Nursing triage category CTAS 3

Vital signs:
 Weight: 20 KG
 Respiratory rate of 58 breaths per minute,
 Heart rate of 154 beats / minute,
 Oxygen saturation of 92%,
 Temperature of 39.2ºC.
 Capillary refill 2 sec
 Blood pressure: 105/70

On exam:

The patient is tachypneic with increased work of breathing, as

evidenced by subcostal and intercostal retractions, head bobbing,
and nasal flaring.
On auscultation, generally poor air entry throughout with wheezing
and has focal area of crackles and decreased aeration.
Cardio: S1+S2+0 no add sound
Abdominal examination: soft and lax abdomen no organomegaly
CNS: no focal neurological deficit

Family history of:

Bronchial asthma
DM
Nasal polyp
Eczema

Provisional diagnoses: BA exacerbation and pneumonia

Estimated PRAM score is 6

Plan of management:

Put the child on bed with vitals sign monitoring

Obtain IV access and draw blood work including

Electrolytes and a VBG (with particular attention to the K)
CBC
CRP
BLOOD CULTURE
CHEST X-RAY 2 VIEW

IV steroids: methylprednisolone 20mg STAT

IV paracetamol 200mg STAT

Salbutamol nebulizers 5 mg (1.0 mL) mixed with ipratropium

bromide 500 mcg
3 doses back to back

Further management as the child condition still not improved

Close monitoring for vitals and BP

IV Magnesium Sulphate 800mg over 20 mins STAT

(In the first hour if possible)

IV NS 20mL/kg bolus (preferably before the MgSO4)

IV Ceftriaxone 1G STAT

IV Maintenance fluid 60 ml / hour D5NS

2 hours post ED management condition improved
Vitals:
Respiratory rate of 30 breaths per minute
Heart rate of 100 beats / minute
Oxygen saturation of 93%,
Temperature of 37.5ºC.
Capillary refill less than 2 sec
Blood pressure: 110/75
PRAM score improved to be 3

ED planned to admit the child under general pediatric ward

Explaining the case summary, indication of admission and the ED

management.
Management to be continued tell adjusted by ward team on:

 Continue vitals monitoring

 Salbutamol nebulizers 5 mg (1.0 mL) Q 4 hours
 IV paracetamol 200 mg Q6 Hours PRN
 IV steroids: methylprednisolone 20mg Q 8 hours
 IV D5NS 60 ml/hour
 Add 20mmol/L KCL as maintenance (adjusted according to
K result)
Ward team came and receive the case
Child shifted to general pediatric ward.