| Advance directives, history, and contacts |
- Determine whether there are restrictions on resuscitation
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- Ask for the patient's emergency card and baseline test results, including electrocardiogram results
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- Obtain a brief history with a focus on baseline respiratory and cardiac status, including use of relevant devices and medications
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- Determine whether the patient is treated with chronic steroid therapy
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- Contact the patient's neuromuscular specialist
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| Breathing problems |
- Ask about respiratory symptoms and home equipment
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- Monitor blood oxygen saturation (SpO2) levels via pulse oximetry; even mild hypoxemia (SpO2 <95% in room air) is a concern; do a blood gas analysis if necessary
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- Treat with non-invasive ventilation and frequent application of a cough assistance device (or manual assisted coughing if device is unavailable); use the patient's home equipment when available
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- Obtain a portable chest radiograph
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- Obtain early consultation with a respiratory therapist and respiratory physician
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| Cardiac problems |
- Ask about cardiac symptoms
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- Monitor heart rate and rhythm
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- Obtain an electrocardiogram (this is typically abnormal and Q waves might be expected) and portable chest radiograph
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- Measure blood levels of B-type natriuretic peptide or troponin I, or both, as indicated
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- Consider worsening cardiomyopathy, congestive heart failure, and arrhythmias
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- Obtain an echocardiogram when necessary
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- Obtain early consultation with a cardiologist
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| Endocrine problems |
- Determine whether stress steroid dosing is necessary
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- For critical adrenal insufficiency, administer intravenous or intramuscular hydrocortisone: 50 mg for children <2 years old; 100 mg for children ≥2 years and adults
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- In less critical situations, consult the PJ Nicholoff Steroid Protocol[1]
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- Obtain early consultation with an endocrinologist
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| Orthopedic problems |
- Assess for long-bone or vertebral fractures as indicated
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- Review critical precautions related to sedation and anesthesia, if applicable
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- Consider fat embolism syndrome if individual has dyspnea or altered mental status
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- Obtain consultation with an orthopedic specialist early in the process
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| Disposition after discharge from emergency care |
- Be aware that most patients will need hospital admission (eg, to initiate or intensify respiratory or cardiac therapy or to manage fractures)
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- Early in the process, initiate emergency transport by skilled personnel to a center specializing in the care of patients with DMD, in cooperation with the individual's neuromuscular specialist
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