What are the initial treatment prescriptions for common emergency department cases?

Emergency Department Treatment Prescriptions for Common Cases

Acute Asthma Exacerbation

For patients presenting with acute asthma to the emergency department, immediately administer oxygen to maintain SpO₂ >90%, nebulized albuterol 5 mg (or terbutaline 10 mg) via oxygen-driven nebulizer every 20 minutes for three doses in the first hour, and systemic corticosteroids (prednisolone 30-60 mg orally OR intravenous hydrocortisone 200 mg) within the first hour of presentation. 1, 2

Initial Assessment and Severity Classification

Upon arrival, obtain objective measurements to classify severity—do not rely on symptoms alone, as failure to recognize severe attacks contributes to preventable deaths 3, 2:

• Mild-to-Moderate (FEV₁ or PEF ≥40% predicted): Patient can complete sentences, pulse <110 bpm, respiratory rate <25/min 3
• **Severe (FEV₁ or PEF <40% predicted):** Cannot complete sentences in one breath, pulse >110 bpm, respiratory rate >25/min 3, 2
• Life-threatening: Silent chest, cyanosis, feeble respiratory effort, bradycardia, hypotension, exhaustion, confusion, or coma 3, 2

First-Line Treatment Protocol

Step 1: Oxygen Therapy

• Administer 40-60% oxygen via nasal cannula or face mask to all patients with acute asthma 3, 1, 2
• Target SpO₂ >90% (>95% in pregnant patients or those with cardiac disease) 1
• Use oxygen as the driving gas for nebulizers 3

Step 2: Bronchodilator Therapy

• Initial dosing: Nebulized albuterol 5 mg (or terbutaline 10 mg) every 20 minutes for 3 doses in the first hour 3, 1, 4
• Alternatively, for patients without nebulizers: 4-8 puffs of albuterol MDI via spacer, repeated every 20 minutes 3
• Continuous nebulization may be used as an alternative: albuterol 7.5 mg/hour has equivalent efficacy to bolus dosing, with no advantage demonstrated for higher doses (15 mg/hour) 5, 6

Step 3: Systemic Corticosteroids (Critical—Do Not Delay)

• Administer within the first hour of presentation 3, 1
• Adult dosing: Prednisolone 30-60 mg orally OR intravenous hydrocortisone 200 mg 3, 1, 2
• Pediatric dosing: 1-2 mg/kg/day (maximum 60 mg/day) 7
• Underuse of corticosteroids is a common factor in preventable asthma deaths 2

Step 4: Add Ipratropium for Severe Cases

• For severe exacerbations (FEV₁ or PEF <40%) or inadequate response to initial beta-agonist therapy, add ipratropium bromide 0.5 mg to the nebulizer with albuterol 3, 1, 2
• Repeat hourly or continuously as needed 3

Reassessment at 15-30 Minutes

Measure PEF or FEV₁, vital signs, and oxygen saturation after initial treatment 3, 1:

• Good response (PEF >75% predicted): Continue SABA as needed, ensure systemic corticosteroids given, consider discharge planning 3
• Moderate response (PEF 50-75% predicted): Continue SABA every 60 minutes, continue systemic corticosteroids, observe for 1-3 hours 3
• Poor response (PEF <50% predicted or persistent severe symptoms): Continue aggressive treatment, consider adjunctive therapies, prepare for admission 3, 1

Adjunctive Therapies for Life-Threatening Exacerbations

When patients remain severely ill despite initial treatment (FEV₁ or PEF <40% after initial therapy) 3:

• Intravenous magnesium sulfate (consider for severe exacerbations unresponsive to initial treatment) 3
• Aminophylline 250 mg IV over 20 minutes OR subcutaneous terbutaline 250 µg over 10 minutes for life-threatening features 3, 2
• Reduce aminophylline loading dose if patient has taken theophylline within 24 hours 3

Critical Pitfalls to Avoid

• Never administer sedatives—they are absolutely contraindicated in acute asthma 1
• Do not give antibiotics unless bacterial infection (pneumonia/sinusitis) is confirmed 3, 1
• Avoid methylxanthines (except aminophylline in life-threatening cases), aggressive hydration, chest physical therapy, mucolytics 3
• Do not discharge patients with persistent tachycardia, tachypnea, or accessory muscle use 3

Hospital Admission Criteria

Admit patients if any of the following persist after initial treatment 1, 2:

• Any life-threatening features present 1
• FEV₁ or PEF <33% predicted after initial treatment 1
• Features of severe attack persist (inability to complete sentences, respiratory rate >25/min, pulse >110 bpm) 3
• Attack occurring in afternoon/evening, recent nocturnal symptoms, recent hospital admission, or previous severe attacks 3

Discharge Criteria and Prescriptions

Before discharge, ensure the following minimum criteria are met 3:

• FEV₁ stable and >50% predicted (ideally >75% with diurnal variability <25%) 3, 7
• Patient demonstrates correct inhaler technique 3
• Patient understands need for follow-up 3

Discharge medications 7:

1. Inhaled SABA (albuterol): 4-8 puffs every 1-4 hours as needed 7
2. Oral corticosteroids: Prednisolone 40-60 mg daily for 5-10 days (children: 1-2 mg/kg/day, max 60 mg) 7
3. Inhaled corticosteroids: Initiate or continue low-to-moderate dose ICS 3, 7

Follow-up requirements 3, 7:

• Contact asthma care provider within 3-5 days after discharge 3
• Schedule follow-up with primary care provider within 1 week 7
• Schedule follow-up with respiratory specialist within 4 weeks 3, 7
• Provide written asthma action plan 3, 7

Monitoring During ED Treatment

• Repeat PEF or FEV₁ measurements at 1 hour and beyond—these are the strongest predictors of hospitalization need 3
• Pulse oximetry for patients in severe distress or with FEV₁/PEF <40% predicted 3
• Presence of drowsiness is a predictor of impending respiratory failure and reason to consider immediate transfer to facility with ventilatory support 3