This corticosteroid also known as Methylprednisolone works by suppressing both chronic and acute inflammation and helps potentiate smooth muscle relaxation. It is indicated for a whole host of chronic obstructive respiratory conditions like asthma, emphysema. We know that asthma and many cases of COPD have inflammation as an underlying cause. The Beta agonists included in your protocol, such as albuterol as well as the anticholinergics, such as Atrovent, can reverse bronchospasm but do little for inflammation. That is where the steroid can complement them so they can better penetrate the airway structures. It has additionally proven valuable in shock conditions like anaphylaxis and acute spinal cord trauma - only during the acute phase for the later.
The last indication for use is one condition in which EMS likely doesn't encounter that frequently -- this is adrenal insufficiency or ADDison's crisis (you need to ADD cortisol because the patient doesn't have enough) The medication works well in all age groups (except premature infants) and is given slow IVP. Of note, you may also want to avoid this - like all steroids - in those patients with fungal infections and those that are immunocompromised because this class of drugs are known to have an inhibitory effect on a broad range of immune responses.
It is a sterile powder and will require reconstitution before use - much like glucagon. The major difference though is the diluent is found within the vial; only separated from the powder by a rubber stopper. Simply break the seal by pressing on the top of the vial (plastic activator), agitate the contents and the mixing will happen from there.
The dose for adults is 125 mg. For our pediatric patients 1-2mg/kg will usually suffice in an emergent setting. Its onset of action is around 1-2 HRS, but don't simply avoid its use in the field strictly because YOU won't see the benefits. It's not about you, it's about the patient and if this could prevent them from being mechanically ventilated via an ETT, that is a win for everyone, and the ED and ICU staff will sing your praises. Better outcomes are absolutely tied to earlier administration.
The image above illustrates what reactive airway disease looks like. As you can imagine, this problem of circumferential swelling is especially problematic in the pediatric populations. Physics tells us that airway resistance is inversely proportional to the radius of the airway. One mm of circumferential edema will reduce the diameter of the airway by 2 mm, resulting in a 16-fold increase in airway resistance for an infant.
PRO TIP #1: If you happen to be on the receiving end of this drug, you will want to avoid its use for months or years on end, as long-term steroid use has been known to cause Cushing's syndrome + related symptoms. Also, don't be surprised if glucose levels rise while taking this medication -- it is known to blunt the effects of insulin and other glucose lowering drugs.
PRO TIP #2: Methylprednisolone is not considered a first line drug in respiratory related emergencies. Don't forget to attend to the patient’s primary treatment priorities (i.e. airway, ventilation, beta-agonist nebulization) first. If they remain refractory to these nebulizers and there is time while in route to the hospital, then methylprednisolone can and should be administered. Do not delay transport to administer this drug.
In emergency medicine we want to see positive effects from our interventions NOW. Dextrose and Naloxone provide us instant gratification. However, Solu Medrol will not, but I want to end with reinforcing that this should not discourage you from using it. Multiple studies have shown a decreased hospital stay, improved lung function and symptoms, reduced treatment failure risk by 50%, and even reduced relapse risk at 1 month. The impact to fighting impending respiratory failure will be tangible... trust me... it just manifests itself after you leave the ED.
Disclaimer - This post is meant to be informational only. As always follow your local protocols -- what your medical director has approved for your agency supersedes anything in the blog!
March 18, 2024
Author: Joshua Ishmael, MBA, MLS(ASCP)CM, NRP
Pass with PASS, LLC.