Acute desaturation Flashcards
You are the IMT1 on call covering the wards at night. You are called by the Senior Nurse on the Acute Medical Unit about Mrs Khan, a **68 year **old lady who has been admitted with an infective exacerbation of her COPD. In addition to her COPD, Mrs Khan has a past medical history that includes T2DM, coronary artery disease and has suffered two myocardial infarctions in the past. She has hypothyroidism and was previously treated for breast cancer.
Since her admission two hours ago she has been started on nebulisers, IV fluids and** IV antibiotics**. The nurse has contacted you as the patient has acutely desaturated and is struggling to breathe. The nurse sounds concerned on the phone.
You are on the phone with the AMU nurse. What information would you want to know over the phone?
I would start asking the nurse whether they think that the patient is going to have a cardiac arrest? If so, advise them to call 2222 and tell them that I am on my way.
I would then ask questions along the lines of ABC.
* Can they speak?
* What are their SpO2 and respiratory rate?
* Do they sound wheezy?
* Are they on oxygen? What volume?
* What is their HR and BP?
* Do they have an increased temperature?
* What is their blood sugar?
I would again reiterate that if they are continuing to deteriorate quickly, to cal the crash team and get help!
The nurse informs you that just before the desaturation the patient was given a penicillin-based antibiotic. They have also developed a rash. She has checked the notes and the patient is allergic to that particular antibiotics.
This is potentially an anaphylactic reaction that has been given, so the pt must be treated as such. Inform the nurse to put out a 2222 call immediately.
If still running, stop the antibiotics immediately.
I would also tell to sit the patient up in bed, give him high flow oxygen via NRB.
If prepared to do so, I would tell the nurse to give 0.5mg IM adrenaline to the patient’s thigh. If not prepared to do so, I would ask her to get the anaphylactic response kit ready.
I would also advise that if the patient has a cardiac arrest, CPR must be started immediately.
What other potential causes are there for this presentation that you should also be thinking about?
Given the presentation, anaphylactic shock is most likely.
However, I would also be mindful of:
1. IECOPD that hasn’t responded to treatment
2. Mucous plugging
3. Sepsis
4. Pulmonary oedema
5. Cardiac cause - further MI (no Hx of chest pain, but patient is diabetic)
6. Pulmonary embolus
What bedside tests could you do to help with your differential list?
Bedside
- Continuous SpO2 monitoring, RR
- 12-lead ECG
- ABG (PaO2, PaCO2)
Bloods
- FBC, CRP, U&E, LFTs, Troponin
- Blood cultures, CRP, urine MC&S
- D-dimer only if PE suspected and pre-test probability low
Imaging
- CXR
- Echo - would not happen right away
You review the patient quickly and decide that she is having an anaphylactic reaction. What would you do?
I would call for help and make sure the nurses have contacted my seniors and 2222. I would check life-threatening features of anaphylactic reaction. These include:
* Airway: swelling, hoarseness, stridor
* Breathing: rapid breathing, wheeze, fatigue, cyanosis, SpO2 < 92%, confusion
* Circulation: clammy, pale, hypotension, faintness, drowsy/coma
If any of these present, I would give IM adrenaline 0.5mg to the anterolateral aspect of the thigh and monitor HR, BP, and SpO2
Reassess ABCat this stage
A
- Airway manouevres (head tilt, jaw thrust)
- I would hope the ITU team is there to prepare for intubation if necessary
B
- High flow O2 for SpO2 88-92% (COPD)
- If wheeze > bronchodilators (salbutamol, ipratropium bromide)
C
- Maintain BP > 100»_space; 500-1000 mL 0.9% NaCl boluses
- Repeat as necessary
You initiate the treatment with IM Adrenaline. Unforunately, Mrs Khan continues to deteriorate and collapses. You assess for a pulse and cannot find one.
What would you do?
- Shout for help
- Pull the crash bell at the end of the bed
- Once help arrives, ask to put out a crash call and come back with a crash trolley
- Start CPR and follow the resuscitation algorithm
- Once the crash team arrives, I would hand over to someone to continue adequate chest compressions and get the defibrillator pads on
- Let the attending team know that this is likely an anaphylactic reaction resulting in Cardiac arrest
How do we learn from events such as this?
Reflection, team-debriefs, incident reporting to allow for proper investigation of this serious events, as it could have been avoided
Mrs Khan is intubated and taken to ITU having been stabilised. Mrs Khan’s husband has now come into the hospital and would like to know what is happening.
Please demonstrate how you would discuss what has happened
I would speak to Mr Khan in a quiet room where we won’t be disturbed and ask someone to hold my bleep.
I would ask Mr Khan what has he been told so far and what is understanding of his wife’s condition is.
I would then fire a warning shot (Unfortunately, there has been a complication).
I would explain that after the initial admission due to worsening of Mrs Khan’s COPD, she was mistakenly given antibiotics that she is allergic to. She had a severe allergic reaction to the antibiotic and despite our best efforts collapsed. She has been intubated and is now in ITU and has been stabilised.
What is duty of candour?
Every healthcare professional must be open and honest with patients when something that goes wrong with their treatment or care causes, or has the potential to cause, harm or distress.
This means that the professionals must:
* Tell the pt when something goes wrong
* Apolgoise to the patient
* Offer an appropriate remedy or support to put matters right
* Explain fully to the pain the short and long term effects of what has happened
Healthcare professionals must also be open and honest with their colleagues, employers and relevant organisations, and take part in reviews and investigations when requested.
If a patient or relative wanted to make a complaint, what could you advise to them?
I would explain the complain process and address them to the Patient Advice and Liaison Service. I would explain how they can do it and would get them a printed flyer from the nurses station.
You now have one minute to handover the patient in this scenario to your registrar/consultant as if you were at the Acute Medical Handover.
Situation: This 68-year-old lady has had an anaphylactic reaction to penicillin and subsequent cardiac arrest.
Background: She was initially admitted today because of an infective exacerbation of her COPD. She was started on an IV penicillin-based drug which she is known to be allergic to.
Assessment: She was initially given IM adrenaline but continued to deteriorate. She was urgently seen by the cardiac arrest team and has had a return of spontaneous circulation. She has been intubated and taken to ITU.
Recommendations: Her husband has come into hospital and I have spoken with him already about what has happened, but he would benefit from speaking with a senior clinician to further explain the situation. An incident report will need to be completed given her history of penicillin allergy was known prior to receiving it.
