ABCDE: Anaphylaxis, Acute Asthma, & COPD Exacerbation Flashcards
Key symptoms in anaphylaxis?
- A feeling of the throat closing up
- Dyspnoea
- Chest tightness
- Nausea and vomiting
- Abdominal pain (especially if caused by food allergies)
What airway problems may be seen in anaphylaxis?
- Difficulty in breathing and/or swallowing
- Hoarse voice
- Stridor
- Swollen tongue and lips +/- saliva drooling
What breathing problems may be seen in anaphylaxis?
- Dyspnoea and tachypnoea
- Wheeze (widespread)
- Cyanosis
What circulation problems may be seen in anaphylaxis?
- Tachycardia: typically a rapid, weak, thready peripheral pulse
- Hypotension
- Cold, clammy skin with prolonged CRT
What skin and/or mucosal changes may be seen in anaphylaxis?
- Widespread urticarial/erythematous rash
- Generalised pruritus
- Angioedema
- Flushing
The onset and the primarily affected organ system can vary depending on the trigger of anaphylaxis.
Describe onset and primarily affected organ system (i.e. breathing or circulation) for anaphylaxis caused by:
1) Food
2) Medication
3) Insect sting
1) Less rapid onset, breathing problems typically predominate
2) Rapid onset, circulation problems typically predominate
3) Rapid onset, circulation problems typically predominate
What are some common causes of sudden onset SOB?
1) Foreign body aspiration
2) Acute epiglottitis (in a child)
3) Acute exacerbation of asthma or COPD
4) PE
5) Pneumothorax
6) Panic attack
What is oral allergy syndrome?
A type I hypersensitivity reaction initiated by cross-reaction with a non-food allergen, such as pollen or latex, involving plant-based foods only.
Unlike anaphylaxis, it usually only causes oropharyngeal symptoms like itching and a tingling sensation, with or without mild swelling of the lips and tongue.
Symptoms tend to fully resolve within one hour post-contact and rarely develop into anaphylaxis, although it is sometimes possible.
What are some other causes of skin rashes or cutaneous flushing?
1) carcinoid syndrome
2) red neck syndrome (from rapid vancomycin infusion)
3) scombroid food poisoning (from contaminated fish)
4) monosodium glutamate poisoning
Assessment, investigations & management of ‘breathing’ in anaphylaxis?
Assessment: RR, O2, signs of respiratory distress, central cyanosis, trachea position, expansion, auscultation & percussion.
Investigations: ABG, CXR
Management: O2 therapy, can give nebulised salbutamol if wheeze is present (bronchospasm).
Assessment, investigations & management of ‘circulation’ in anaphylaxis?
Assessment: HR & character, BP, temp, CRT, JVP, fluid status, auscultation.
Insert 2x wide bore cannulae.
Investigations: bloods (FBC, U&Es, LFTs, coagulation, CRP, serum tryptase), ECG.
Management: fluid bolus if hypotensive (500ml 0.9% saline over 15 mins), IM adrenaline (1:1000)
What is the 1st line treatment for anaphylaxis?
IM 0.5ml adrenaline 1:1000.
Repeat every 5 minutes.
If no improvement after 2 administrations –> consider IV adrenaline infusion (expert input).
If patient with anaphylaxis has a wheeze, what can be considered?
Nebulised salbutamol +/- nebulised ipratropium bromide (500mcg)
Purpose of ECG in anaphylaxis?
To look for evidence of acute myocardial ischaemia, which may occur secondary to anaphylaxis.
What dose of IM adrenaline is given for an adult with anaphylaxis?
0.50ml of 1:1000 adrenaline
Repeat every 5 mins as necessary
When is a serum mast cell tryptase recommended in anaphylaxis?
1) Where diagnosis is uncertain
2) In children <16 if the cause is thought to be venom-related, drug-related, or idiopathic
Although an elevated serum mast cell tryptase level confirms the diagnosis of anaphylaxis, a normal result does not rule out anaphylaxis.
Dosing of adrenaline in ALS vs anaphylaxis for adults?
ALS –> IV or IO 10ml (1mg) of 1:10,000
Anaphylaxis –> IM 0.5ml (500 micrograms) of 1:1000
Assessment & investigations in ‘disability’ in anaphylaxis?
AVPU
Pupils
Temp
Drug chart review
Glucose & ketones
Once the patient has been stabilised in anaphylaxis, what medication can be offered?
Non-sedating oral antihistamines (e.g. cetirizine) - to treat skin symptoms.
Clinical features of acute asthma?
- Shortness of breath
- Wheeze
- Tachypnoea
- Hypoxia
PEFR in moderate vs severe vs life-threatening asthma exacerbation
Moderate: >50-70% of best or predicted
Severe: 33-50%
Life-threatening: <33%
What defines a near-fatal asthma exacerbation?
Raised PaCO2 and/or requiring mechanical ventilation with raised inflation pressures.
What category of asthma exacerbation is O2 sats <92%?
Life-threatening
What category of asthma exacerbation is HR ≥110?
Severe
Assessment, investigations & management of ‘breathing’ in acute asthma?
Assessment: O2, RR, signs of distress, cyanosis, trachea position, expansion, auscultation, percussion
Investigations: ABG, PEFR, CXR
Interventions: SIT PATIENT UP! O2 therapy, nebuliased salbutamol, steroid therapy, ipratropium bromide, consider magnesium sulphate, consider IV aminophylline
Purpose of PEFR in acute asthma?
PEFR can be used to assess the severity of the patient’s asthma exacerbation and their subsequent response to treatment.
However, PEFR recording shouldn’t delay the administration of oxygen and nebulised medications.
1st line treatmnet in management of acute asthma?
A high-dose inhaled beta-2 agonist (i.e. salbutamol)
How is salbutamol delivered in mild/mod, severe vs life-threatening asthma?
Mild/mod: use either pressurised multiple-dose inhaler (pMDI) plus spacer or oxygen-driven nebulisation to administer salbutamol.
Severe: use oxygen-driven nebulisation to administer salbutamol.
Life-threatening: use continuous oxygen-driven nebulisation to administer salbutamol.
How often should doses of salbutamol be repeated in acute asthma?
Repeat at 15-30 min intervals
or
Give continuous nebulised salbutamol at 5-10 mg/hour if there is an inadequate response to initial treatment.
How can salbutamol be given if there is an inadequate response to initial treatment?
Can be given continuously at 5-10mg/hour
1st line management of acute asthma?
1) Nebulised salbutamol
2) Oral prednisolone / IV hydrocortisone (if oral route unavailable)
3) Add nebulised ipratropium bromide if severe or life-threatening asthma (or those with a poor initial response to beta-2 agonist therapy)
What dose of oral prednisolone is given in acute asthma?
40-50mg
How long is oral prednisolone continued for following an asthma attack?
at least 5 days after exacerbation or until recovery
Who should nebulised ipratropium bromide given to in acute asthma?
1) severe or life-threatening asthma
2) poor initial response to beta-2 agonist therapy
Dose of ipratropium bromide given in acute asthma?
0.5mg 4-6 hourly
In patients with life-threatening/near-fatal asthma who are not responding to intial therapy, what 2 medications can be considered?
1) IV magnesium sulphate (single dose)
2) IV aminophylline
These should only be used following consultation with senior medical staff.
What additional investigation may be useful under ‘breathing’ in COPD exacerbation?
Sputum culture - useful later to understand the causative organism and its antibiotic sensitivities.
1st line management of COPD exacerbation?
1) Nebulised salbutamol
2) Nebulised iratropium bromide 500 micrograms (if patient does not respond adequately to nebulised salbutamol)
3) Steroids (ALL patients) –> oral prednisolone 30mg once a day for 5 days
How should salbutamol be given in COPD exacerbation if the patient is hypercapnic or acidotic?
Driven by compressed air rather than oxygen (to avoid worsening hypercapnia).
How often should doses of salbutamol be repeated in COPD exacerbation?
At 15-30 min intervals, or give continuous nebulised salbutamol at 5-10 mg/hour.
When shuld ipratropium bromide be given in COPD exacerbation?
If the patient does not respond adequately to nebulised salbutamol.
Dose of ipratropium bromide given in COPD exacerbation?
500 micrograms
How is ipratropium bromide given in COPD exacerbation?
Ipratropium bromide can be given with salbutamol in the same nebuliser.
What dose of oral prednisolone is given in COPD exacerbation?
30mg daily for 5 days
If 1st line interventions fail in COPD exacerbation, what should you do?
Escalate care.
Consider:
1) NIV for persistent hypercapnic respiratory failure.
2) Respiratory stimulants and intravenous theophylline.
Typical signs & symptoms of pulmonary oedema?
Symptoms:
- SOB
- Pink frothy sputum
Signs:
- Tachypnoea
- Decreased O2 sats
- Raised JVP
What 2 investigations are indicated in ‘breathing’ in pulmonary oedema?
1) ABG
2) CXR
What CXR features may be seen in pulmonary oedema?
1) Bilateral peri-hilar shadowing
2) Blunting of the costophrenic angles
3) Fluid in the fissures (e.g. right horizontal fissure)
4) Kerley B lines
Interventions in ‘breathing’ in pulmonary oedema?
1) Sit patient up
2) O2: non-rebreathe mask with an oxygen flow rate of 15L
What bloods may be useful in pulmonary oedema?
1) FBC
2) U&Es
3) LFTs
4) CRP
5) Troponin
6) Plasma BNP
Investigations & interventions in ‘circulation’ of pulmonary oedema?
Investigations:
- ECG
- Bloods from cannula
Interventions:
- Diuretics
What is an ECG looking for in pulmonary oedema?
- evidence of acute myocardial ischaemia
- ventricular hypertrophy
- arrhythmias
What is the mainstay of management of pulmonary oedema?
1) Sit patient up
2) O2 therapy
3) IV loop diuretics e.g. furosemide
What intervention is considered for patients with pulmonary oedema who do not improve after supplemental oxygen and IV diuretics?
CPAP
Who should loop diuretics be used with caution in in pulmonary oedema?
Hypotensive patients –> therefore critical care input should be sought
