The chest is exposed to conduct an assessment. The patient is in a private residence and the unit has a warm temperature.
Vital signs
RR: 32 bpm
HR: 130 bpm
BP: 100/54 mmHg
SpO2: 87%
Blood glucose: 4.3 mmol/L
Temperature: 37.2 °C
Peak expiratory flow reading (PEFR): unable to record
GCS: E4, Verbal – not complying with your questioning, only stating he cannot breathe, M6
4 Lead ECG: sinus tachycardia, regular
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.
Using the latest guidelines from the Australia and New Zealand Thoracic Society (ANZTS), the British Thoracic Society (BTS) or a source that draws on these resources, compare and contrast the differences between life‐threatening asthma and anaphylaxis, and explain why this is more likely to be asthma than any other differential diagnosis.
Similarities: asthma and anaphylaxis both present with respiratory distress and a wheeze. Both are due to an inflammatory response. And both may appear flushed – from exertion in asthma, and in anaphylaxis the skin’s reaction to the allergen.
Differences: in anaphylaxis the whole airway can be affected, producing particular symptoms not associated with asthma, such as voice changes, stridor, inspiratory wheeze and tongue and lip swelling. Also asthma is predominantly a respiratory problem, whereas anaphylaxis can present with gastrointestinal problems and hypotension, which can lead to distributive shock.
Although this did occur after eating, the patient seems to be presenting with symptoms limited purely to the respiratory system. There are no dermatological, gastrointestinal or cardiovascular changes that would indicate anaphylaxis.
1 Is this patient suffering from moderate, severe or life‐threatening asthma, and why? Life‐threatening asthma. See Table 1.4.Table 1.4 Comparison of asthma severitySource: British Thoracic Society (2019).Near‐fatal asthmaRaised PaCO2 and/or requiring mechanical ventilation with raised inflation pressuresLife‐threatening asthmaIn a patient with severe asthma any one of: PEF <33% best or predicted SpO2 <92% PaO2 <8 Kpa ‘Normal’ PaCO2 (4.6–6.0 Kpa) Altered conscious level Exhaustion Arrhythmia Hypotension Cyanosis Silent chest Poor respiratory effortAcute severe asthmaAny one of: PEF 33–50% best or predicted Respiratory rate ≥25/min Heart rate ≥110/min Inability to complete sentences in one breathModerate acute asthmaIncreasing symptoms PEF >50–75% best or predicted No features of acute severe asthma
1 List your treatment, route and dosages. Adrenaline – 500 μg IM.Salbutamol – 5 mg nebulised.Ipatropium bromide – 500 μg nebulised.Oxygen – 6/8 L.Hydrocortisone – 100 mg IV (IM possible if unable to gain IV access).
Case Progression
You treat this patient rapidly with 500 μg of intramuscular (IM) adrenaline while your crewmate administers 5 mg of salbutamol and ipratropium bromide via a nebulizer, on 6 L of oxygen. After nebuliser therapy and 1 dose of IM Adrenaline, you rapidly extricate your patient to the ambulance. You deliver a pre‐alert to the nearest emergency department.
Patient assessment triangle
General appearance
Alert and now looking at you and nodding or shaking his head in response to your questions.
Circulation to the skin
Pale.
Work of breathing
Increased work of breathing – breathing still rapid, but less shallow.
SYSTEMATIC APPROACH
Danger
None at this time.
Response
Alert.
Airway
Clear and peripherally cyanosed.
Breathing
RR:28. Audible wheeze on auscultation.
Circulation
HR: 128. Palpable radial. Capillary refill time 2 seconds. Nail beds appear bluish.
Disability
Moving all four limbs.
Exposure
Normal temperature in the ambulance.
Vital signs
RR: 28 bpm
HR: 128 bpm
BP: 110/78 mmHg
SpO2: 91%
Blood glucose: not repeated
Temperature: not repeated
GCS: 15/15
4 lead ECG: sinus tachycardia
1 This type of incident may lead to high levels of stress during the time you are with the patient. Name at least four short‐term effects of stress. Increased heart rateIncreased blood pressurePupil dilationSweatingIncreased blood sugar levelsInhibitions of digestive secretionsPeripheral vasoconstrictionBronchodilationSource: ANZ (2015).
2 It is important to recognise symptoms of long‐term (chronic) stress in yourself or others. Name at least two long‐term effects of stress. Behaviour changes:Difficulty sleeping.Altered eating habits.Smoking/drinking more.Avoiding friends and family.Sexual problems.Physical responses:Tiredness.Indigestion and nausea.Headaches.Aching muscles.Palpitations.Mental responses:Increased indecision.Difficulty concentrating.Poor memory.Feeling inadequate.Low self‐esteem.Emotional responses:Mood swings, becoming irritable or angry.Increased
