Airway Is the patient able to talk? - if so the airway is patent Noisy breathing suggests airway compromise Perform Head tilt, Chin lift If noisy breathing persists try a Jaw Thrust If airway still appears compromised use an airway adjunct Use a Oropharyngeal Airway (Guedel) if unconscious, otherwise they may gag & aspirate vomit Or alternatively use a Nasopharyngeal airway (well tolerated if patient is somewhat conscious) Breathing Sit up in bed Give High Flow Oxygen via a Non-rebreathe mask – 15 Litres – 100% Give nebulised bronchodilators: Salbutamol 5mg Nebulised – repeat every 15 mins if life threatening features present¹ Ipratropium Bromide 500mcg Nebulised – every 4-6 hours¹ Assess Respiratory rate Oxygen saturation – aim to keep as high as possible (94-98%) – if <92% this is life threatening Air entry (auscultation) - pleural rub may be present in PE, absent breath sounds in pneumothorax Percussion – hyper-resonance may suggest pneumothorax Expansion – may be unilaterally reduced in pneumonia with consolidation Peak flow – useful to assess severity/ response to treatment -repeat every 15-30 mins Chest X-ray - rule out pneumothorax – portable CXR machine – don’t delay treatment whilst waiting [Broken External Image]:http://geekymedics.com/wp-content/u...-Screenie-at-2012-06-27-00-02-251-600x377.png Grading of severity of asthma in adults – SIGN guidelines² Circulation Assess BP Capillary Refill Time - central (as may be peripherally shut down) – should be <2 seconds Pulse ECG – patient may have rhythm problem contributing to shortness of breath – e.g. Fast AF Gain IV access – large bore cannula – e.g. 14 Gauge Take blood samples - FBC, U&E, LFT, Clotting, CRP, Cultures Perform regular ABG’s: PaO2 – is there type 1 respiratory failure? (<8.0kPa) pH – may be alkylotic initially due to hyperventilation, acidosis is a poor prognostic sign PaCO2 – often low due to hyperventilation – if rising patient likely needs ITU support (CPAP) Give Hydrocortisone- 100mg IV (can alternatively give oral prednisolone 40-50mg)¹ If patient still not stable then ITU/Anaesthetist/Seniors need calling to attend immediately You can institute the following treatment after discussion with your senior (i.e. whilst they’re on their way) Magnesium Sulphate – 1.2-2.0g IV over 20 minutes¹ Once Seniors/ITU involved then the following may be tried: Aminophylline – not a drug you would start as a junior doctor – need cardiac monitoring for arrhythmias If no improvement or life threatening features are present consider intubation & ITU transfer Disability Assess AVPU - reduced consciousness may indicate severe hypoxia / hypercapnia Assess Pupils - constricted in opiate overdose, dilated in TCA overdose, blown in brain pathology Exposure Expose patients entire body looking for Rash – seen in anaphylaxis, meningococcal septicaemia Hidden sources of bleeding Hidden sources of sepsis / infection - i.e.infected leg ulcer Other secondary injuries Hot swollen calf may suggest DVT – important if PE suspected Reassess ABCDE Important to keep reassessing ABCDE Allows you to recognise if the treatment you have initiated is working Also allows fast recognition that the patient is not responding to treatment & is deteriorating If patient continues to deteriorate, seniors/ITU need to be involved sooner rather than later Further management Once the patient is stabilised they will need admitting to a ward If infective source is found then appropriate antibiotics should be initiated They will require regular observations – PEFR/Oxygen saturations/RR Record PEFR before & after salbutamol at least 4 times whilst in hospital¹ Wean down & stop aminophylline over 12-24hrs (if initially started on it)¹ Reduce nebulised bronchodilators (Salbutamol & Ipratropium) – switch to inhaled Salbutamol Wean off oral steroids gradually & initiate inhaled corticosteroid (Beclamethasome) Continue to monitor PEFR, looking out for early signs of deterioration on reduced treatment Investigate underlying cause of acute exacerbation of asthma – allergic? infective? Source
