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Respiratory Emergencies

Acute Severe Asthma

  1. Assess severity and warn ITU
  2. Start treatment immedately before investigations: PEF, ABG, CXR (pneumothorax, infx), FBC, U+E O' SHIT (oxygen, salbutamol, hydrocortisone, ipratropium, theophylline)
  3. Sit patient up and give 100% Oxygen via non-rebreathing bag
  4. Salbutamol 5mg plus ipratropium bromide 0.5mg nebulized with Oxygen
  5. Hydrocortisone 100mg IV
  6. CXR to exclude pneumothorax
  7. Further management :
  8. If not improving in 15-30 mins: salbutamol nebs back to back, continue ipratropium
  9. If still not improving:
    • Senior review, discuss with ITU
    • Magnesium sulphate
    • Consider theophylline
  10. If still no improvement: consider ITU admission accompanied with doctor prepared to intubate

Severe

Life-threatening

Before discharge patient must:

Acute exacerbation of COPD

  1. Controlled Oxygen therapy with venturi mask (Start at 24%, vary according to ABG)
  2. Nebulised bronchodilators: salbutamol 5mg/4h, ipratropium 0.5 mg/6h
  3. Steroids: IV hydrocortisone 200mg
  4. ABX: if evidence of infx (eg amoxicillin)
  5. Ix: PEF, ABG, CXR, FBC, U+E, CRP, Cultures of blood and sputum, ECG
  6. Physiotherapy to aid sputum expectoration
  7. If no response: repeat nebulizers and consider IV aminophylline
  8. If no response:
    • Consider nasal intermittent positive pressure ventilation (NIPPV)
    • Consider intubation and ventilation
    • Consider a respiratory stimulant eg doxapram

Pulmonary Embolism

Most deaths occur within the first hour, so if good story and signs start treatment
  1. Oxygen 100%
  2. Morphine 10mg with anti-emetic for pain
  3. IV access and start heparin
  4. Then consider systolic BP:
    less than 90mmHg
    1. Rapid colloid infusion, dobutamine.
    2. If BP still low consider noradrenaline.
    3. If BP still < 90mmHg after 30-60min consider thrombolysis
    over 90 mmHg
    Start warfarin
  5. Ix: Bloods: U+E, FBC, clotting
    ECG: right axis deviation, RBBB, AF, S1Q3T3
    ABG
    CT pulmonary angiography or VQ scan
    D-dimer
  6. 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

  1. Aspirate with large bore needle in 2nd intercostal space (above the rib) midclavicular line
  2. Chest drain: 4-6 intercostal mid-axillary line

Pneumonia

  1. O 2 to maintain PaO 2 >8 (Caution if hx of COPD)
  2. Treat hypotension and shock
  3. 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
  4. Antibiotics:
    Community Acquired
    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.
    • Mild: Amoxiciilin and erythromycin
    • Severe: Co-amoxiclav IV and erythromycin
    • Atypicals: Legionella (clarithromycin), Chlamydia (tetracycline), Pneumocystis (co-trimoxazole)
    Hospital Acquired
    Gram negatives: give aminoglycoside IV
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