The Severe Asthmatic: Atrovent, Albuterol, Corticosteroids, Magnesium.. And Low-dose Ketamine…

To watch the lecture, click the YouTube Video!

With patients experiencing severe asthma exacerbation you generally need to do four interventions:

  1. Administer oxygen
  2. Administer short acting beta-agonists (such as albuterol)
  3. Administer Atrovent
  4. Administer some type of corticosteroid such as Solumedrol

So back in the pre-COVID days, we’ve all had that crashing asthmatic patient. You did all of the usual things; administered oxygen, set up a dual neb, performed a 12-lead ECG, hooked up ETCO2 monitoring, and obtained IV access. Vitals were as follows:

Heart Rate: 160 BPM sinus tachycardia on the 12-lead ECG.

Blood Pressure: 105/72

Room air saturation: 60% (73% with Oxygen via NRB mask and a dual neb going)

Respirations: 30 with wheezing noted in all lobes of the lungs.

ETCO2: 55 mmHg with the shark fin waveform noted below.

Your non-rebreather mask with a dual neb attachment isn’t exactly doing the trick with this patient so what would be your next step? Try some BiPAP/CPAP. You try to place the patient on it but they become super anxious and combative as they have a mask forced onto their face. Instead of giving a benzodiazepine like midazolam, have you thought about the wonderful drug Ketamine?

Ketamine can be used for a lot of situations. Combative psychiatric patient? KETAMINE. Patient with extensive burns? KETAMINE. Anxious hypoxic patient on the brink of cardiac arrest? KETAMINE. Could low-dose ketamine be the preferred drug to calm down an anxious hypoxic patient? It’s been shown to cause bronchodilation. Ketamine does this by increasing catecholamine levels which then bind to the beta receptors and cause smooth muscle relaxation/bronchodilation. Additionally, it doesn’t cause respiratory depression like other sedatives.

Please follow your local protocols. Don’t just administer Ketamine to every asthmatic patient and say:

Now back to the post. You’ve calmed your patient down with Ketamine enough so they accept the CPAP/BiPAP. Their O2 saturation is increasing slightly but they’re still sticking around the low 80s. You have an IV established because you’re a stellar provider and you realize you need a medication that can help these patient. You decide on magnesium sulfate. This medication can be used for several reasons such as with Torsades de Pointes, eclampsia, pediatric acute nephritis, hypomagnesemia, and severe asthma attacks because it acts as a bronchodilator. Now the specific mode of action is relatively unknown but there are a few interesting theories. One is that magnesium sulfate inhibits the cells from uptaking calcium across the smooth muscles which leads these muscles to relax. Another theory is that magnesium sulfate decreases the release of histamines from mast cells through the power of degranulation) pictured below:

So now that you have a magnesium drip started and you’re infusing 1.2g – 2g over 20 minutes, you notice the patient’s oxygen saturation has gone up to 92%. Your patient is improving! Are you done? Well lets check the list we mentioned at the top of the post:

  1. Administer oxygen… CHECK
  2. Administer short acting beta-agonists (such as albuterol)… CHECK
  3. Administer Atrovent… CHECK
  4. Administer some type of corticosteroid such as Solumedrol… X

So you’re missing a corticosteroid. If you’re a prehospital provider with short ETAs to the hospital, you may wonder why you’d give this to your patient…? Some might say “It takes a while to kick in and it won’t affect your patient while they’re with you.” Remember that we need to be advocates for our patients. If you administer a corticosteroid in the field, the patient may drastically improve at a much faster rate in the hospital as opposed to if you didn’t administer it. It could possibly mean the difference in the patient being discharged that day or being admitted.

Asthma is a frequent condition that all medical providers will encounter. Knowing the best way to treat the patient so they have a positive outcome, is even more important.

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This site is meant to be used for educational use only. We strive to push evidence based medicine with no bias to help you obtain all the important information. You should always follow your protocols that have been set in place.

Scopeducation Team (Matt)


Gern MD, James. “Magnesium Sulfate and Acute Severe Asthma?” Medscape, 11 Feb. 2005,

Grayson, Kelly. “Use Capnography as a Primary Assessment Tool for Asthma and COPD Exacerbation.” CapnoAcademy, 10 Sept. 2019,

Kokotajlo, Suzannah, et al. “Use of Intravenous Magnesium Sulfate for the Treatment of an Acute Asthma Exacerbation in Pediatric Patients.” The Journal of Pediatric Pharmacology and Therapeutics : JPPT : the Official Journal of PPAG, Pediatric Pharmacy Advocacy Group, Apr. 2014,

Saadeh, Constantine K. “What Is the Role of Ketamine in the Treatment of Status Asthmaticus?” Latest Medical News, Clinical Trials, Guidelines – Today on Medscape, 17 June 2020,

Sullivan, Bob. “EMS Assessment and Treatment of Asthma: 5 Things to Know.” CapnoAcademy, 10 Sept. 2019,,of%20CO2%20to%20be%20eliminated.&text=Pulse%2Doximetry%20is%20useful%20to,is%20often%20a%20late%20finding.

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