HPI:
52 year old man presenting via CFD wtih acute onset of shortness of breath. Per CFD patient was sitting on the edge of his couch holding his inhaler with moderate respiratory distress. En route he was given 2 treatments of nebulized bronchodilators without much improvement in symptoms. The patient is refusing to lay on cart sitting on edge of cart, anxious appearing with only one word answers to questions.
From a brief review of electronic medical record you see:
Past Medical History: HTN, asthma (moderate persistent)
Medications: Combivent MDI, Singulair, Lisinopril, HCTZ
Allergies: NKDA
Social History: 20 pack year smoking history - continues to smoke 1/2 pack per day
Vital Signs:
T 99.2F HR 100 BP 154/92 RR 40 SaO2 88% on 2L via NC
Gen: middle aged man in moderate respiratory distress
HEENT: clear op otherwise unremarkable
Neck: habitus limits jvd assessment, no visible jvd
Pulm: exp wheezing diffusely, no rales, intercostal retractions and tracheal tug noted
CV: tachycardic, reg rhythm, no murmurs, normal s1/s2, no rubs
Abd: soft, nd, nt, +bs
Extrem: 2+ distal pulses throughout
Neuro: alert, oriented, no focal motor/sensory deficits
Skin: warm, no rashes noted
ED Course:
As you ordered patient started on continuous neb, given IV methylpred, mag sulfate while IV, O2 via NRB started and placed on monitor. Respiratory is en route with noninvasive ventilation and your tech is setting up intubation equipment and RSI medications in case necessary...
Labs are not yet back however you have access to the following EKG and CXR...
Despite continuous neb, iv corticosteroids and mg sulfate patient continues to have moderate respiratory distress... repeat vitals are obtained:
T 99.5F HR 130 BP 102/64 RR 44 SaO2 90% on NRB
- What is the diagnosis? What treatment needs to be initiated for this?
General questions pertaining to asthma management in the ED...
- What criteria can be used to determine suitability for admission to the hospital for patients with asthma exacerbations?
- What criteria can be used to determine readiness for discharge from the ED or hospital?
---------------------- (scroll down for answers)-------------------------
Diagnosis: Tension Pneumothorax
Treatment: Needle decompression and chest tube placement
What criteria can be used to determine suitability for admission to the hospital for patients with asthma exacerbations?
After treatment in the emergency department for 1 to 3 hours, patients who have an incomplete or poor response, defined as an FEV1 or PEF of less than 70% of the personal best or predicted value, should be evaluated for admission to the hospital. Patients who have an FEV1 of less than 40%, continuing moderate-to-severe symptoms, drowsiness, confusion, or a partial pressure of arterial carbon dioxide of 42 mm Hg or greater should be admitted.
What criteria can be used to determine readiness for discharge from the ED or hospital?
According to the authors, patients may be discharged if the FEV1 or PEF after treatment is 70% or more of the personal best or predicted value and the lung function and improvement of symptoms are sustained for at least 60 minutes. After discharge, patients should continue to use inhaled short-acting β2-adrenergic agonists as needed and should be prescribed oral corticosteroids for 3 to 10 days. Reference:
Lazarus, S. Emergency Treatment of Asthma. N Engl J Med 2010; 363:755-764
