Respiratory

emergencies
Amy Bullock
amy.bullock@students.plymouth.ac.uk
 • What’s happening •Travel history
HISTORY • How long for
• Pain – SOCRATES - •PMHx
worse on inspiration?
• SOB •Medications
• Cough
•FHx
• Sputum
• Haemoptysis •Social history
• Noisy breathing –
stridor, wheeze
 • General inspection: do they
look well?
• Hands: clubbing, cyanosis,
tremor, tar staining
• Arms: blood pressure, RR
EXAM • Face: cyanosis, pallor
• Neck: swellings, lymph node
examination, trachea
• Chest: look, listen, feel
• Legs: swelling, red, hot,
 • Haemoptysis
• Cough >3weeks
Red flags • Long smoking history
• Unintentional weight loss
• Night sweats
• Persistent fevers
• Reduced saturations
 19yr old Jake - very short of breath. Cannot
complete full sentences so difficult to get a
thorough history. Had a bit of a cold for past
few days but normally fit and well.
• PMHx: asthma, nil else

Case 1 • Meds: Ventolin, Fostair

• On examination, widespread bilateral
wheeze, not cyanosed.
• No angioedema, no urticaria

• RR 32, HR 125, BP 120/80, T37, SpO2 93%,

Differentials
• Asthma exacerbation
• Anaphylaxis
• Foreign body
• PE
 Cannot complete full sentences
Not cyanosed
Asthma exacerbation – severity Wheezy throughout
RR 32, HR 125, BP120/80, SpO2 93%,

MODERATE LIFE THREATENING

• PEF >50-75% best • PEF <33%
• SpO2 <92% // PaO2< 8kPa
• Silent chest
SEVERE ACUTE • Cyanosis
• PEF 33-50% best • Poor resp effort
• RR >/=25 • Arrhythmia
• HR >/=110 • Exhaustion
• Unable to complete sentences • Altered consciousness
• Hypotension
 Asthma
exacerbations are life
threatening
In 2018 – 1422 deaths
3 people die every day with
an asthma attack
Management – OSPIT
• Pre hospital – 10puffs of reliever inhaler (SPACER), often have an instruction sheet to guide them

• O2 at 94-98%
• Salbutamol nebulisers 5mg – oxygen driven
• Prednisolone 40-50mg for 5 days
• Ipratropuim bromide nebs 0.5mg 4-6hourly
• IV magnesium sulphate
• IV aminophylline
• Intubation ventilation

• Admit AND follow up

Asthma vs COPD exacerbation management
Asthma
• Oxygen 94-98%
• Salbutamol nebs
• Prednisolone 40-50mg 5days
• Ipratropium bromide nebs
• IV magnesium sulphate
COPD – infective or non infective
• Oxygen, need to identify whether CO2
retainer
• Salbutamol OR saline nebs
• Prednisolone 30mg 5-7days
• Ipratropium bromide nebs
• Antibiotics; amoxicillin/ doxycycline/
clarithromycin
• NIV, IV theophylline
 Case 2
• 1400  30F left sided chest pain, stabbing, sudden onset 7am but worsening –
now 7/10. Worse on inspiration. Feels a bit short of breath.
• New cough, no haemoptysis, no sputum
• PMHx: Nil Now you mention it
• Meds: microgynon, NKDA her calf really does
hurt and has for a
• Travel history: came back from Australia last week few days
• FHx: nil
• SHx: smoker 10/day, drinks 20Units/ week

• O/E: HR 103, BP 130/89, T36.7, spO2 98% L calf very painful, red hot and swollen
Differentials Investigations
• PE • Bloods
• Pneumonia • FBC, CRP, UE, LFT, troponin
• Calculate her Wells score
• Pneumothorax • ?D-dimer or CTPA
• Costochrondritis • ABG
• MI • CXR
• ECG
What does this ECG show?
CTPA
 • If CTPA cannot be carried out immediately –
ANTICOAGULATE
• Monitor in case they become
haemodynamically unstable

PE • PESI score; prognostic stratification

management • CTPA has confirmed presence of a PE

• Treatment dose apixaban for PE 10mg BD 7
days then 5mg BD maintenance
• Anticoagulant education and alert cards
• Follow up in clinic
 Massive PE
• Sustained hypotension (systolic <90) requiring inotrope support,
pulseless or persistent profound bradycardia

• Thrombolysis first line if cardiac arrest is imminent

• 50mg alteplase bolus

• Thrombus fragmentation and IVC filters

 • 60M, walks into A&E with • O/E:
Case 3 sudden onset SOB and chest
pain, stabbing, worse on • HR95, RR27, BP155/90,
inspiration spO2 92%
• No fevers, no haemoptysis, • Alert
dry cough (ongoing 6months),
weight loss, night sweats
• No recent travel • General inspection pt looks
SOB
• PMHx; HTN, nil else
• Finger clubbing
• Meds; ramipril NKDA
• On examination of the chest
• FHx: nil – reduced chest expansion,
reduced breath sounds and
Hyperresonance on R side.
• SHx: smoker 50 pack years,
drinks 30U/week, lives at
home alone, retired bus driver
Differentials Investigations
• Pneumothorax • Immediately treat?
• Primary • CXR
• Secondary
• Tension
• ECG
• Pneumonia • Bloods
• FBC, UE, CRP, LFT
• PE
• MI
Aspiration with 16G cannula Surgical chest drain
Others
MCQs
What does this ABG show?
a. Type 2 respiratory failure • pH: 7.3 (7.35-7.45)
b. Type 1 respiratory failure • paO2: 6.8 (7.5-10)
c. Respiratory acidosis • paCO2: 8 (3.5-4.5)
d. Metabolic acidosis
• HCO3: 32 (22-28)
A. TYPE 2 RESPIRATORY
FAILURE
- acidotic, hypoxic, CO2 retainer,
chronic changes
 a. Bordered by pectoralis minor,
6th intercostal space and
serratus anterior
b. 2nd intercostal space,
Where is the midclavicular line
triangle of c. 5th intercostal space mid
axilliary line
safety d. Bordered by axilla, pectoralis
major, latissimus dorsi and 5th
intercostal space
Where is the triangle
of safety

d. Bordered by axilla,
pectoralis major, latissimus
dorsi and 5th intercostal space
What is this
diagnosis?
a. Pneumonia
b. COVID19
c. Pulmonary oedema
d. Pneumothorax
What is this
diagnosis?
a. Pneumonia

b.COVID19
c. Pulmonary oedema
d. Pneumothorax
COVID19 management *currently*
• Symptoms: cough, SOB, loss of taste and smell, diarrhoea, vomiting, feeling
generally unwell, off legs  EVERYTHING

• Diagnosis: swabs, CXR, bloods (typically high neutrophils and low lymphocytes)

• Management: dependent on risk category

• Oxygen
• Dexamethasone 6mg
• Antibiotics; co-amoxiclav/ doxycycline
• Remdesivir vs Tocilizumab?
• For or not for escalation – NIV…
 a. Sinus bradycardia
What is the
‘textbook b. S3T1Q3
finding’ for
PE on c. S1Q3T3
ECG?
d. Pleural rub
 What is the ‘textbook finding’ for PE on ECG
C. S1Q3T3
 • Asthma facts and statistics | Asthma UK
• BTS_SIGN Asthma Guideline Quick Reference G
uide 2016.pdf
• Advanced Management Options for Massive a
nd
Submassive
Extra Pulmonary Embolism | USC Journal
• British Thoracic Society guidelines for the man
reading and agement of suspected acute pulmonary emboli
sm | Thorax (bmj.com)
references • Pneumothorax | Acute Management | ABCDE
| Geeky Medics
• Pneumothorax – AMBOSS
• Covid-19 controversies: the tocilizumab chapte
r | The BMJ
• COVID-19: Dexamethasone in adults (nice.org.
uk)
 Thank you
Any questions?

amy.bullock@students.plymouth.ac.uk
Pulmonary oedema

• Sit patient upright

• 100% O2
• IV morphine – helps anxiety with
breathing, if already exhausted- avoid
• Antiemetic
• Furosemide 50mg IV, repeat 30mins-
1hour (can double dose when repeating)
• GTN
• CPAP, NIV
• Critical care review - ?inotropes, invasive
ventilation