– irregular. Capillary refill time 2 seconds.
Disability
Pupils equal and reactive to light (PEARL).
Exposure
The patient is in his own home.
Vital signs
RR: 36 bpm
HR: 110 bpm
BP: 150/90 mmHg
SpO2: 86%
Blood glucose: 4.5 mmol/L
Temperature: 37.8 °C
PEF: unable to record
GCS: 15/15
4 Lead ECG: atrial fibrillation
Allergies: nil
TASK
Look through the information provided in this case study and highlight all of the information that might concern you as a paramedic.
What is COPD?
COPD is a progressive disease and is characterized by air flow obstruction that is not fully reversible. The airway obstruction results from damage to alveoli, alveolar ducts and bronchioles due to chronic inflammation.
List the features of an acute exacerbation of COPD.
Increased dyspnoea.
Increased sputum production.
Increased cough.
Upper airway symptoms, such as a cold and sore throat.
Increased wheeze.
Reduced exercise tolerance.
Fluid retention.
Increased fatigue.
Acute confusion.
Worsening of previously stable condition.
Case Progression
After administration of 5 mg salbutamol via nebuliser, the patient’s condition improves slightly and he hands you a medical card that his ‘breathing doctor’ gave to him. The card states the patient is at risk of retaining CO2 and should only be administered with 28% oxygen to achieve saturations between 88 and 92%.
Patient assessment triangle
General appearance
Alert and more interactive.
Circulation to the skin
Pink.
Work of breathing
Increased work of breathing – breathing rapid, but not as shallow as before.
SYSTEMATIC APPROACH
Danger
None at this time.
Response
Alert.
Airway
Clear.
Breathing
RR: 30. Audible wheeze on auscultation.
Circulation
HR: 120. Palpable radial. Capillary refill time 2 seconds.
Disability
Moving all four limbs.
Exposure
Normal temperature in the ambulance.
Vital signs
RR: 30 bpm
HR: 120 bpm
BP: 148/78 mmHg
SpO2: 90%
Blood glucose: not repeated
Temperature: not repeated
GCS: 15/15
4 lead ECG: atrial fibrillation
Allergies: nil
1 When the nebuliser has finished, you notice that the patient’s SpO 2 is dropping so you decide to keep the patient on oxygen. What percentage of oxygen would you administer to this patient and why?28% oxygen through a nasal cannula. The patient is at risk of developing hypercapnia respiratory failure, so it is important the oxygen is titrated to maintain saturations between 88 and 92%. Research suggests that over‐oxygenation increases the mortality and morbidity of COPD patients and that titration of oxygen administration can reduce mortality.
2 What is meant by the term hypercapnia? ‘A condition of abnormally elevated carbon dioxide (CO2) levels in the blood, caused by hypoventilation, lung disease, or diminished consciousness’ (NAEMT, 2015, p. 92).‘Alveolar hypoventilation with increased alveolar carbon dioxide limits the amount of oxygen available for diffusion into the blood, leading to secondary hypoxemia’ (McCance et al., 2010, p. 1269).
LEVEL 2 CASE STUDY
Pulmonary embolism (PE)
| Information type | Data |
| Time of origin | 17:55 |
| Time of dispatch | 18:01 |
| On‐scene time | 18:10 |
| Day of the week | Friday |
| Nearest hospital |
