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Teaching series 3: A–E assessment in Respiratory Emergency DeliveredDr Arwa Ali - FY1 Kettering General Hospital Delivere: Dr Momna Raja- SFP doctor- FY1 Kettering General HospitalQuick introduction Dr Arwa Ali FY1 Kettering General Hospital Arwa.ali4@nhs.net Dr Momna Raja SFP doctor FY1 Kettering General Hospital Momna.raja@nhs.netDisclaimerLearning objections • Learn how to acutely manage respiratory emergencies • Conduct an A-E assessment Case 1 • You are a medical oncall during nights. A nurse bleeps you as she is concerned aboutMrs Stewart (45 years old) who is suddenly short of breath and making ‘additional airway noises’. BG HTN, asthma, T1DM, 50 pack year smoking history. • Obs = RR = 26bpm, Sats = 81% on air, HR = 110bpm, BP = 135/90, temp = 38.9oC. • How did you proceed? Airway • Patent • Patient is speaking in full sentences. • Appears breathless and distressed • Wheeze BREATHING • Look: • End of bed – accessory muscle use, SOB, distressed, coughing • Peripheral or central cyan– none • Feel • Trachea central • chest expansion.- equal, symmetrical but reduced • Percussion– resonant • Listen: • Reduced air entry at the bases, widespread wheeze • ObsR = 26bpm,Sats = 81% on air BREATHING .. CONTINUED • Investigations • ABG & CXR • Covid swab, Sputum culture. • Peak flow • Treatment • 15L of oxygen via a-rebreathe mask • Back-to-back nebs– Salbutamol 5mg + Ipratropium 500 micrograms • Steroids Arterial Blood Gas • ABG results • pH – 7.37 • pCO2– 5.5 kPa • pO2 – 11 kPa on 15L of oxygen • HCO3– 26 mEq/L • O2Hb– 88% Impression: T1RF CIRCULATION • Look: • No Peripheral or central cyanosis, JVP = not raised • Feel • Temperature = warm peripherally • CRT < 2seconds • Pulse : Regular • Listen: • HS I + II + 0 • Obs: HR= 109bpm, BP = 109/77CIRCULATION .. CONTINUED • Investigations • ECG • IV access • Bloods (FBC, U&Es, LFTs, CRP, VBG) DISABILITY •Assessment • Pupils – equal and reactive • AVPU– Alert • Temperature = 36 o.C •Investigations: BM – 28mmol/L •Ketones = 0.1 EXPOSURE + EVERYTHING ELSE • Abdominal examination : soft, non-tender with no palpable masses • Exposure (rash, bleeding, drains, catheter ) • Squeeze calves • Gather information -> full clinical Hx, collateral Hx, patient notes, drug chart. Once complete -à Repeat A-E Diagnosis? Acute exacerbation of AsthmaAssessment of Asthma severity Severity Symptoms Moderate PEF > 50-75% best or predicted No features of acute asthma Acute severe PEF: 33-50% of best predicted RR >25bpm HR > 110bpm Unable to complete full sentences Life threatening - SHOCK PEF <33% best or predicted SpO2 <92%, paO2 <8kPa, normal PaCO2 (4.6 -6kPa) Altered consciousness, Hypotension, cyanosis, Poor respiratory effort Silent chest Near fatal asthma raising PaCO2Treatment O’ SHIT ME • O – Oxygen • S – Salbutamol 5mg • H – Hydrocortisone or Prednisolone • I – Ipratropium 500 micrograms • T – Theophylline/Aminophylline • M – IV Magnesium sulphate 2g over 2 mins • E - Escalate for Senior review +/- ITU Case 2 • You are the surgicalon1all during nights. You get bleeped by the nurse as they are concerned by Mrs Wakerwho is reporting shortness of breath and chest pain. She is 3-days post hemi-arthroplasty. BG of HTN and OA. • Obs –RR = 45 bpm, Sats = 89% on air, BP = 101/78, HR = 120bpm, temp = 36.8oC, Alert. • How will you proceed? Airway • Speaking in full sentences • No additional airway sounds BREATHING • Look: • End of bed– accessory muscle use, • Peripheral or central cyanosi yes • Feel • Tracheacentral • chest expansion. equal, symmetrical but reduced • Percussion– resonant • Listen: • Reduced air entry at the bases • Obs; RR = 45 bpm, Sats = 89% on air BREATHING .. CONTINUED • Investigations • ABG & CXR • ABG results • pH – 7.48 • pCO2– 3.3 kPa • pO2 – 9.2 kPa on 15L of oxygen • HCO3– 25 mEq/L • O2Hb– 84% Impression: Respiratory alkalosis with T1RF CIRCULATION • Look: • No Peripheral or central cyanosis, JVP = 8cm. • Feel • Temperature = warm peripherally • CRT < 2seconds • Pulse : Regular • Listen: • HS I + II + Ejection systolic murmur • Obs: HR= 112bpm, BP = 125/77CIRCULATION .. CONTINUED • Investigations • ECG • IV access • Bloods (FBC, U&Es, LFTs, C-dimer) Deep S wave ECG ECG [1] T wave Impression: Sinus Tachycardia, S1Q3T3, T wave inversion in inferior inversion Q inversion DISABILITY •Assessment • Pupils – equal and reactive • AVPU– Alert • Temperature = 36 .C •Investigations: BM – 5.5 EXPOSURE + EVERYTHING ELSE • Abdominal examination : soft, non-tender with no palpable masses • Exposure (rash, bleeding, drains, catheter ) • Squeeze calves • Gather information -> full clinical Hx, collateral Hx, patient notes, drug chart. Once complete -à Repeat A-EHamptons Hump Picture taken from Radiopedia [2] Diagnosis? Pulmonary embolismCase 2 - Nice guidelines Nice recommends, use of WELLS score Other scoring systems: - Modified Geneva score - PERC For prognosis, use PESI score. Treatment •Hemodynamically stable • Treatment dose LMWH or DOAC • Provoked – 3 months • Unprovoked – 6 months •Hemodynamically unstable– Alteplase •CTPA •Additional considerations: USS Legs Case 3 You are a medical F1 on the wards. You are bleeped Wosae r r. (85-year-old gentle) who is short of breath. BG: HTN, IHD. He is currently in hospital being treated for Urosepsis. How did you proceed? Airway • Patent • Patient is speaking in full sentences. Appears breathless • Things you can comment on: • Look: Inside mouth (+/- suction) • Listen: additional airway sounds – snoring, stridor, wheeze. BREATHING • Look: • End of bed – accessory muscle use, tripod positioning • Peripheral or central cyanosi– none • Feel • Tracheacentral • chest expansion.- equal and symmetrical • Percussion– bibasal dullness. • Listen: • Reduced air entry at the bases • Scattered crackles • Obs; RR = 28bpm, regular. Sats = 80% on room air BREATHING .. CONTINUED • Investigations • ABG & CXR • ABG results • pH – 7.37 • pCO2– 5.1 kPa • pO2 – 10 kPa on 15L of oxygen • HCO3– 25 mEq/L Impression: T1RF CIRCULATION • Look: • No Peripheral or central cyanosis, JVP = 8cm. • Feel • Temperature = warm peripherally • CRT < 2seconds • Pulse : Regular • Listen: • HS I + II + Ejection systolic murmur • Obs: HR= 112bpm, BP = 125/77CIRCULATION .. CONTINUED • Investigations • ECG • Bloods (FBC, U&Es, LFTs, CRP, Tropon-dimer), D DISABILITY •Assessment • Pupils – equal and reactive • AVPU– Alert but drowsy • Temperature = 38 •Investigations: BM – 5.5 EXPOSURE + EVERYTHING ELSE • Abdominal examination : soft, non-tender with no palpable masses • Exposure (rash, bleeding, drains, catheter ) • Squeeze calves • Pitting scrotal and peripheral pedema oedema •chart.r information -> full clinical Hx, collateral Hx, patient notes, drug Once complete -à Repeat A-ETaken from Radiopedia [4] Diagnosis? Pulmonary oedema CXR changes [5] Mnemonic ABCDE • A: Alveolar opacification • B: Batwinging • C: Cardiomegaly • D: Diffuse interstitial thickening (Septal lines) and upper love diversion • E: Effusions Treatment LMNOP • L – Loop diuretics (IV Furosemide) • M – Morphine • N– Nitrates • O – Oxygen – target 94-98% • P – Position upright, Positive airway pressure (CPAP) • Other considerations: Fluid restrict to 1.5L, Fluid balance chart, daily weights and U&Es.References 1. Available at: https:/www.grepmed.com/images/4350/clinical-electrocardiogram-d. cardiology-s1q3t3-ecg (Accessed: November 4, 2022). 2. https://radiopaedia.orgcases/75579/studies/86853?langgb&referrer=%2Farticles%2 Fpulmonary-embolism%3Flang%3Dgb%23image_list_item_52294958 (Accessed: November 4, 2022). 3. Burns, E., Cadogan, M. and Cadogan, E.B.and M. (2022)Myocardial ischaemia, Life in the Fast Lane • LITFL. Available at: https://litfl.com/myocardial-ischaemia-ecg-library/ (Accessed: November 4, 2022). 4. Bandura, P.J. (2022) Pulmonary Oedema: Radiology reference article, Radiopaedia Blog RSS. Radiopaedia.org. Available at: https://radiopaedia.orgarticpulmonary- oedema?lang=gb (Accessed: November 4, 2022). 5. Elsaka, O., 2021. Heart Failure: Causes, Investigations and Updates on Management.FOR FEEDBACK AND QUERIES: Email @info@bidasw.com
