A 22-year-old female presents via ambulance to the Emergency Department (ED) in the early hours of the morning with acute shortness of breath on the background of a 5-day history of cough, fever and general malaise.
She has no past medical history, no regular medications and no drug allergies. She has had several negative COVID lateral flow tests over the last few days.
The nurse-in-charge moves her to the resuscitation area due to her profound breathlessness.
Her observations and examination findings are as follows:
A – Patent, self-maintained.
B – RR 25, SpO2 100% on oxygen-driven nebuliser from crew, 94% on room air 10 minutes post-nebuliser.
You observe features of respiratory distress with accessory muscle use and an inability to speak in full sentences. On auscultation, there is poor air entry throughout, with occasional bilateral, expiratory wheeze.
C – BP 124/67, HR 139 with a sinus tachycardia on 12-lead ECG. Normal jugular venous pressure (JVP). No pedal oedema.
D – Alert, BM 6.1. No neurological abnormalities.
E – Temp 37. Abdomen soft, non-tender. No signs of deep vein thrombosis (DVT) in lower limbs.
She has been treated by the crew with one mixed nebuliser of Salbutamol 5mg and Ipratropium Bromide 500mcg and a further two Salbutamol nebulisers, one of which is still ongoing.
An arterial blood gas (ABG) is taken while the patient is on the latest oxygen-driven nebuliser:
pH 7.32 (7.35-7.45)
pCO2 5.14 (4.6-6.1kPa)
pO2 14.0 (10-13kPa)
HCO3 19.6 (22-28mmol/L)
BE -5.9 (-2 – +2)
Lactate 3.86 (0.5-2.2mmol/L)
You perform a bedside chest X-ray, which is as follows:
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Question 1 of 3
1. Question
Which of the following steps is the most appropriate in the further management of this patient?
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Question 2 of 3
2. Question
The patient is still in the department 9 hours later, stable, and awaiting a medical bed. She remains in the Resuscitation/High-Care area and you are the clinician covering.
The nursing staff ask you for an urgent review, as she is complaining of acute breathlessness and looks to be in distress.
Your assessment of her is as follows:
Patent, self-maintained.
RR 35, SpO2 88% on room air. You observe features of accessory muscle use, and a globally quiet chest with the odd scattered crepitation bilaterally. There is no wheeze.
BP 128/63, HR 123 with a sinus tachycardia evident on the monitor. Heart sounds are normal and her JVP is unremarkable.
She is alert but extremely anxious and appears confused.
Temp 37.6. No new rashes or changes to the initial examination.
Whilst you consider your next management step, she suddenly becomes cyanosed and her oxygen saturations plummet, which you treat with high flow oxygen via a non-rebreathe mask.
Which of the following are appropriate immediate next steps in her management? (Select all that apply).
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Question 3 of 3
3. Question
You ready the drugs and equipment for intubation and the ITU registrar arrives. There are no features suggestive of a difficult airway and you therefore agree to be the first intubating clinician. You follow the SOAPME checklist5.
You pre-oxygenate the patient and perform induction with Propofol and Rocuronium.
On intubating, you have a grade 3 view that is not improved by the BURP manoeuvre. Your first attempt leads to a suspected oesophageal intubation and so the ITU registrar attempts and fails a second intubation using direct laryngoscopy. The oxygen saturations start to drop.
According to the DAS (Difficult Airway Society) Guidelines, what is the correct next step?
This session is about the pathophysiology of acute coronary syndromes, defining acute myocardial infarction and recognising the various presentations and clinical features associated with acute coronary syndromes.
6 Comments
Nice one.
Good case
Well presented
Nice one
good case which illustrated the management options very well
Good review of the guideline. I find PEF terribly unreliable in acute asthma – especially in the ‘untrained’ patient like this.