Respiratory Emergencies: Life-threatening Asthma, tension pneumothorax, PE, Respiratory failure, Pulmonary Edema Flashcards
What are the classic signs and symptoms of life-threatening asthma?
33 92 A CHEST mnemonic: If a patient has one of the following it is life-threatening asthma
PEFR is less than 33% of personal best
Oxygen saturation is less than 92%
C: Cyanosis and confusion
H: Hypotension: Dizziness, weakness, blurred vision, fainting
E: Exhaustion
S: Silent chest
T: Threatening PEF
How do you manage life-threatening asthma?
OSHITME mnemonic
O: High-flow oxygen
S: Nebulised salbutamol, ideally oxygen-driven
H: Hydrocortisone
I: Ipratropium bromide
T: Theophylline
M: Magnesium sulfate
E: Escalate care
In life-threatening asthma management, how is high-flow oxygen administered and what should the result be?
High-flow oxygen through tight fitting mask or nasal cannula
Keep oxygen saturation between 94-98%
In life-threatening asthma management, what dose of nebulised salbutamol is given, and in what kind of nebuliser?
5mg for adults, 2.5mg for children
Ideally air-driven nebuliser to prevent risk of overoxygenation, otherwise use oxygen-driven nebuliser
In life-threatening asthma, what dose and route is used to administer hydrocortisone?
100mg IV hydrocortisone
In life-threatening asthma, what is the second-line steroid that should be used if hydrocortisone can’t be used?
Prednisolone 40-50mg PO
In life-threatening asthma, what is the mechanism of ipratropium bromide, and give 2 reasons why it is used?
Anticholinergic drug used to control symptoms of bronchospasm
Added to nebulised salbutamol to increase initial response and has minimal side effects
In life-threatening asthma management, what dose and route is used to administer ipratropium bromide?
500 micrograms NEB for adults, 250 micrograms NEB children aged 2-12
In life-threatening asthma management, what dose and route is used to give theophylline?
1g aminophylline infusion IV
In life-threatening asthma management, what dose and route is used to give magnesium sulfate, and for how long?
Stat dose 2g magnesium sulfate IV
Given over 20 minutes
What is the role of magnesium sulfate in treating life-threatening asthma?
Produces rapid and marked bronchodilation
What is flail chest?
Life-threatening condition where segment of rib cage breaks due to trauma and detaches from chest wall
What are the 4 classic signs of flail chest?
Paradoxical movement of chest wall where broken segment draws in when patient inhales and chest expands, and segment moves out when patient exhales and chest shrinks
Dyspnea
Chest pain
Bruising in affected area
What are the 5 early symptoms of tension pneumothorax?
SOB
Pleuritic pain radiating to ipsilateral back and shoulder
Tachypnea
Tachycardia
Hypotension
What are the 5 early signs of tension pneumothorax?
Cyanosis
Jugular venous distension
Chest retractions
Tracheal deviation
Hypotension
What is the emergency management of tension pneumothorax in 2 steps?
- Needle decompression in 2nd intercostal space on mid-clavicular line
- Administer high flow oxygen
What are the causes of cardiac and non-cardiac pulmonary edema? (NOT CARDIAC)
Cardiac: Heart failure
N: Near drowning
O: Oxygen therapy
T: Transfusions reaction TRALI
C: CNS (neurogenic)
A: Allergic reaction
R: Renal failure
D: Drugs
I: Inhaled toxins
A: Altitude eg. ARDS
C: Contusion
Give 6 signs of pulmonary edema?
SOB during movement or lying down
Haemoptysis or pink frothy mucus
Wheezing or gasping
Cold and clammy skin
Anxiety
Palpitations
If you suspect someone has a pulmonary edema, what radiological investigation should you do and what are the 3 classic signs?
CXR in PA view
Cardiomegaly
Kerley-B lines
Batwing opacities
If you suspect a patient has pulmonary edema, what are the 3 classic signs in a respiratory exam?
JVP
Ankle/peripheral edema
Crackles on auscultation
What is the acute management of pulmonary edema? (POND)
P: Position
O: Oxygen
N: Nitroglycerin
D: Diuretics
Which 6 lab investigations should you do to confirm pulmonary edema?
BNP blood test: Elevated
ABG: Low PaO2 and low PaCO2, if PaCO2 is normal or raised this indicates patient is exhausted and not ventilating properly
Troponin: Acute MI could cause heart failure
U&Es
LFTs: hypoalbuminaemia
FBC
How should you position a patient with pulmonary edema, in acute management?
Patient should be sitting up straight
Corrects V/Q mismatch and allows gravity-dependent drainage of capillary leaks
How do you administer oxygen therapy to patients with pulmonary edema, in acute management?
Non-rebreathe mask with 15L oxygen flow rate
In which 3 cases is nitroglycerin used to treat pulmonary edema?
Concomitant MI
Severe hypertension
Mitral regurgitation
Which diuretic is used for acute management of pulmonary edema?
Furosemide
What is type 1 respiratory failure and type 2 respiratory failure?
Type 1 respiratory failure: Failure of gas exchange which causes hypoxaemia (PaO2 less than 8) and normocapnia (PaCO2 less than 6)
Type 2 respiratory failure: Failure of gas exchange and ventilation which causes hypoxaemia and hypercapnia (PaCO2 more than 6)
What is the main pathophysiology of type 1 respiratory failure?
Ventilation/perfusion mismatch
What is the main pathophysiology of type 2 respiratory failure?
Alveolar hypoventilation
Give 4 causes of type 1 respiratory failure?
Pnemonia
Pulmonary edema
Bronchoconstriction
PE
Give 4 causes of type 2 respiratory failure?
COPD exacerbation
Opiate/sedative overdose
Rib fractures
Guillain-Barré syndrome
Which investigations should you do for respiratory failure?
FBC
Sputum culture
ABG
CXR
Obs
What are the 5 signs of severe asthma attack?
Peak flow of 33%-50% of their best or predicted PEFR
Oxygen saturations of less than 92%
Unable to complete sentences in one breath
Respiration rate over 25 breaths per minute
Heart rate more than 110 beats per minute.
What are the 5 signs of a moderate asthma attack?
Peak flow of less than 50%-75% of their best or predicted PEFR
Oxygen saturations of more than 92%
Speaking in full sentences
Respiration rate below 25 breaths per minute
Heart rate below 110 beats per minute.
