CASE
You have been called to an outdoor running track for an 18‐year‐old female with shortness of breath. The caller states she has taken her inhaler to no effect.
Pre‐arrival information
The patient is conscious and breathing. You can access the area via the back gate of the sports field and drive right up to the patient, who is sat down on the track.
Windscreen report
The location appears safe. Approx. 10 people around the patient. Environment – warm summer evening and good light.
Entering the location
The sports coach greets you as you get out of the ambulance and informs you that the patient suffers with exercise‐induced asthma, but this is worse than normal and her inhaler has been ineffective.
On arrival with the patient
The patient is sat on a bench on the side of the track. She is leaning forward, resting her elbows on her thighs (tripodding). She says hello as you introduce yourself to her.
Patient assessment triangle
General appearance
Alert. Speaking in short sentences. She looks panicked.
Circulation to the skin
Flushed cheeks.
Work of breathing
Breathing appears rapid and shallow. An audible wheeze is noted.
SYSTEMATIC APPROACH
Danger
None at this time.
Response
Alert on the AVPU scale.
Airway
Clear.
Breathing
RR: 28. Regular and shallow. No accessory muscle use. Expiratory wheeze on auscultation.
Circulation
HR: 100. Regular and strong. Capillary refill time <2 seconds. Flushed cheeks and peripherally warm.
Disability
Moving all four limbs.
Pupils equal and reactive to light (PEARL).
Exposure
Bystanders have left. Next of kin are now on scene.
Temperature: warm summer evening – approx. 20 °C.
Vital signs
RR: 28 bpm
HR: 100 bpm
BP: 125/74 mmHg
SpO2: 93%
Blood glucose: 5.2 mmol/L
Temperature: 36.9 °C
PEF: 300 L/min
GCS: 15/15
4 Lead ECG: sinus tachycardia
TASK
Look through the information provided in this case study and highlight all of the information that might concern you as a paramedic.
Aside from auscultation, which you have already done, what examination techniques should you incorporate into this patient assessment? Inspection – observe the chest for an abnormalities such as wounds, scars, bruising, asymmetry and recession.Palpation – feel for any asymmetry, vocal fremitus and tenderness.Percussion – hyper‐ or hypo‐resonance.
What adventitious (added) sounds might indicate asthma and why? Expiratory wheeze. This sound is made when air has a restricted path through the bronchi, due to inflammation and muscle spasm in the airways.
What medicine (pharmacology) is likely to relieve the patient’s symptoms and why? Nebulised salbutamol – it is a Beta2, adrenergic agonist that relaxes smooth muscle in the bronchi.
Case Progression
You treat the patient with 5 mg of nebulised salbutamol and 6 L of oxygen. The nebuliser finishes and you remove the mask.
Patient assessment triangle
General appearance
The patient is now speaking in full sentences.
Circulation to the skin
Flushed.
Work of breathing
Normal effort of breathing.
SYSTEMATIC APPROACH
Danger
None at this time.
Response
Alert.
Airway
Clear.
Breathing
RR:16. Regular. Normal depth. No accessory muscle use. No wheeze or adventitious sounds.
