It’s very difficult to see what’s going on with this patient on paper, but there are several unusual things here that makes this case not-you-typical-asthmatic.
(1) Which asthmatic gets intubated 50 times? None.
(2) The patient must have been perfectly fine before she went to psych (otherwise she would not have been sent). Why would she suddenly have this terrible asthma attack?
(3) Why does she have stridor?
Without an IV, the best drugs for a severe asthmatic are SQ Epi, SQ Epi, nebs, and SQ Epi. We couldn’t get an IV into her because she was a terrible stick and she was quite agitated.
We put an end tidal CO2 on her. The reading was 39.
After watching her not respond to the nebs and the epi, she looked like a patient headed toward an intubation. I decided to give her 5&2 IM. It worked after a few minutes. The patient calmed down, the stridor went away, and the wheezing nearly vanished.
The patient had vocal cord dysfunction. I’ve seen this in a few patients before. It’s debated whether this is a psych problem, a medical problem, or both. It’s obvious why these patients get intubated so frequently – they look like they’re going to die from an asthma attack.
Before this patient arrived, I was talking to the residents about things that don’t matter in the ED – lactate, d-dimer, clinical decision rules, attendings…. Attendings don’t make much of a difference in patient care most of the time, but occasionally you need one.
https://www.ncbi.nlm.nih.gov/pubmed/?term=dunn+n+vocal