Respiratory Emergencies
Acute Severe Asthma
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Assess severity and warn ITU
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Start treatment immedately before investigations: PEF, ABG, CXR (pneumothorax,
infx), FBC, U+E
O' SHIT (oxygen, salbutamol, hydrocortisone, ipratropium,
theophylline)
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Sit patient up and give 100% Oxygen
via non-rebreathing bag
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Salbutamol 5mg plus ipratropium bromide 0.5mg nebulized with
Oxygen
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Hydrocortisone 100mg IV
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CXR to exclude pneumothorax
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Further management
:
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If not improving in 15-30 mins: salbutamol nebs back to back, continue
ipratropium
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If still not improving:
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Senior review, discuss with ITU
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Magnesium sulphate
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Consider theophylline
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If still no improvement: consider ITU admission accompanied with
doctor prepared to intubate
Severe
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Unable to complete sentences
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RR>25/min
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Pulse>110 beats
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PEF<50% of predicted or best
Life-threatening
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PEF<33% of predicted or best
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Silent chest, cyanosis, feeble respiratory effort
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Bradycardia or hypotension
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Exhaustion, confusion, coma
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ABGs: normal/high PaCO2
,
PaO2
<8, low pH (NB: normal CO2 is a
life-threatening feature)
Before discharge patient must:
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Inhaler technique checked
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PEF>75%
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Review of drugs
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Own a PEF, have a management plan
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GP appointment within 1 week
Acute exacerbation of COPD
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Controlled Oxygen
therapy with venturi mask (Start at 24%, vary
according to ABG)
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Nebulised bronchodilators: salbutamol 5mg/4h, ipratropium 0.5 mg/6h
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Steroids: IV hydrocortisone 200mg
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ABX: if evidence of infx (eg amoxicillin)
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Ix: PEF, ABG, CXR, FBC, U+E, CRP, Cultures of blood and sputum, ECG
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Physiotherapy to aid sputum expectoration
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If no response: repeat nebulizers and consider IV aminophylline
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If no response:
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Consider nasal intermittent positive pressure ventilation (NIPPV)
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Consider intubation and ventilation
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Consider a respiratory stimulant eg doxapram
Pulmonary Embolism
Most deaths occur within the first hour, so if good story
and signs start treatment
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Oxygen 100%
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Morphine 10mg with anti-emetic for pain
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IV access and start heparin
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Then consider systolic BP:
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less than 90mmHg
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Rapid colloid infusion, dobutamine.
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If BP still low consider noradrenaline.
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If BP still < 90mmHg after 30-60min consider
thrombolysis
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over 90 mmHg
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Start warfarin
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Ix:
Bloods: U+E, FBC, clotting
ECG: right axis deviation, RBBB, AF, S1Q3T3
ABG
CT pulmonary angiography or VQ scan
D-dimer
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Subsequent management: TED stockings, heparin 5d (until INR>2),
warfarin 6m (unless post-op where it is only continued for 3m)
Occurs classically
10d post-op with collapse and sudden breathlessness while straining at
stool.
RFs
Malignancy, surgery, immobility, The Pill, previous, thrombophilia
Prevention
Early post-op mobilization, TEDs, heparin, avoid CoC, anticoagulation,
VC filters
Signs/Symptoms
Acute dyspnoea, pleuritic chest pain, haemoptysis, syncope
hypotension, tachycardia, gallop rhythm, raised JVP, loud
P2
, RV heave, pleural rub, tachypnoea, cyanosis
Pneumothorax
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Aspirate with large bore needle in 2nd intercostal space
(above the rib) midclavicular line
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Chest drain: 4-6 intercostal mid-axillary line
Pneumonia
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O
2
to maintain PaO
2
>8 (Caution if hx of COPD)
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Treat hypotension and shock
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Ix:
CXR
Sats, ABG
Bloods: FBC, U+E, LFT, CRP, atypical serology
Blood and sputum cultures
Pleural fluid may be aspirated for culture
Bronchoscopy and bronchoalveolar lavage if immunocompromise
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Antibiotics:
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Community Acquired
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Depends on the CURB65 score: Confusion, Urea >7mmol/L,
Repiratory rate >30, BP < 90 mmHg, Age > 65. 0-1: Home
treatment, 2 hospital therapy, >2 indicates severe.
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Mild: Amoxiciilin and erythromycin
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Severe: Co-amoxiclav IV and erythromycin
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Atypicals: Legionella (clarithromycin), Chlamydia
(tetracycline), Pneumocystis (co-trimoxazole)
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Hospital Acquired
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Gram negatives: give aminoglycoside IV