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Profoundly sick patient, call for help, don't panic instead focus on ABCs and you can work it out
|Acutely Ill Patient
|Causes of breathlessness predominately
|Uncommon in adults but can occur at all ages. Usually a drooling, quiet child with stridor. If concerns about airway summon anaesthetist urgently before examining in case there is acute obstruction. Classic 'tripod' position of the patient, drooling, high fever, and a toxic appearance. In the presence of respiratory distress, diagnostic procedures and radiography are not indicated, and securing the airway should be prioritized with the availability of a team capable of performing an immediate tracheotomy.
|Upper airway obstruction - stridor
|laryngeal oedema, inhaled foreign body, burns. Inspect and remove if possible. Anaesthetic help. If intubation impossible then a cricothyrotomy may be needed. An incision is made through the cricothyroid membrane and standard tracheostomy tubes can be inserted. An alternative is needle cannulation of the cricothyroid membrane with a large gauge intravenous needle inserted at 45 degrees. The escape of air confirms positioning. The introducer needle can be removed, and the plastic cannula fed on down. Attach a 3ml syringe to the catheter which can be attached to a 7 mm ET tube adaptor to allow bag-valve ventilation using 10-15L/min of oxygen. Stridor may suggest anaphylaxis and the need for IV Hydrocortisone and Chlorpheniramine and adrenaline.
|Quick chest exam to assess air entry. Hyper-resonant quiet side may be a Pneumothorax. CXR diagnostic. If PTX and falling BP consider Tension PTX below.
|Quick chest exam to assess air entry. Hyper-resonant overinflated quiet side may be a Tension Pneumothorax which pushes the trachea away from the affected side and reduces cardiac output. Patients in extremis and BP falling. There is no time for a CXR and a needle must be inserted 2nd ICS on the affected resonant side with the sudden release of air. If you choose the wrong side then simply do the other. Context important and maybe ventilated patient, recent central line insertion or chest would and trauma. Once pressure relived insert a chest drain.
|Pleural effusion or consolidation
|Dullness could be fluid or consolidation. Get a CXR. Drain effusion. May require intubation and ventilation if in respiratory failure. Bronchoscopy to pull out inhaled foreign bodies.
|common. Dyspnoeic, Raised JVP,RV heave, Loud P2, signs of DVT. CXR often normal. Elevated dimers and risk factors. Anti-coagulate. Thrombolysis in selected severe cases.
|Exacerbation of COPD
|Pre-existing COPD. Type 2 RF on ABG. Wheezy. Consider NIV or if acidotic then discuss ITU admission with intensivists
|Acute severe asthma
|Known Asthmatic. Reduced PEFR. Wheezy
|Acute dyspnoea, Basal crackles, triple rhythm. Worse lying flat. CXR diagnostic. ECG to look for STEMI needing PPCI. Echo when possible
|Dullness, reduced air entry, pleurisy, fever, raised WCC and CRP. Consolidation on CXR may not be seen very acutely.
|Hypoventilating respiratory failure
|COPD, Obesity, Sedation, CO2 narcosis, respiratory muscle weakness
|Respiratory muscle weakness
|High cervical cord lesion, Guillain Barre syndrome, Myopathy, Motor neuron disease, muscular dystrophies. Monitor FEV and FVC
|Metabolic acidosis 'Kussmaul breathing'
|DKA, salicylate overdose etc
|Setting of stress or anxiety. Examination normal. Respiratory alkalosis.
|Causes of Shock/Hypotension
|Complete heart block
|needs Atropine, inotropes and external and then temporary pacing
|VT or compromising tachyarrhythmia
|DC countershock. Amiodarone, Magnesium.
|May be warm and vasodilated, Fever, Raised WCC, Raised CRP. Fluids + antibiotics immediately
|Bee sting, nuts, drug. IM Adrenaline + Hydrocortisone
|Gastrointestinal with haematemesis or melaena on glove. Hidden bleeding e.g. retroperitoneal, psoas particularly in those on Warfarin. Haemorrhagic pancreatitis.
|STEMI, Myocarditis. Needs Echo. STEMI which needs only an ECG to diagnose needs PPCI
|Raised JVP, Hypotension, Globular heart on CXR. Needs Echo. Needs drainage.
|Acute Aortic regurgitation.
|Marked EDM. Usually endocarditis or dissection or trauma. Needs medical and surgical management.
|Acute Mitral regurgitation
|Marked PSM. Endocarditis or papillary muscle infarction.
|Acute Ventricular septal defect
|Marked PSM. seen post MI
|Purpura - Antibiotics + Fluids + ITU
|Ruptured Abdominal aortic aneurysm
|Fluids and Vascular surgeons
|Dissecting thoracic aorta
|lower BP in left arm or pulseless with pain into back. CT chest. Supportive and cardiothoracic referral
|Ruptured abdominal viscus
|Free air under diaphragm. Rigid abdomen. Needs supportive measures and surgical review
|Diabetic ketoacidosis, Diabetes insipidus. Polyuria, Hypernatraemia.
|external signs may be apparent. Needs trauma review and CT head and neurosurgeons. Look for Haemorrhage, Oedema
|large haemorrhage with raised ICP (cerebellar bleeds do well with surgery), Large infarct with oedema (consider hemicraniectomy), Secondary hydrocephalus needing shunting
|Reduce Insulin, Glucagon, 50 ml of 50% IV dextrose
|IV Naloxone 0.8-2.0 mg stat and repeated as half-life short
|Supportive if fitting has stopped
|Post cardiac arrest
|jaundice, abnormal LFTs, signs of liver failure
|Consider alcohol, opiates, sedations, benzodiazepines and antidotes