phuluong2k
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A 25-year-old patient with asthma arrives at the emergency department complaining of extreme shortness of breath. He has been compliant with his medications, which are metaproterenol and inhaled betamethason
Over the past 6 hours, his wheezing and shortness of breath have become increasingly severe
At present, his blood pressure is 136/84 mm Hg and with deep inspiration falls to 116/56 mm Hg. His pulse is 126/min, and respirations are 32/min and labored. There is retraction of the sternocleidomastoid muscles with inspiration. There are soft wheezes and poor air movement diffusely throughout both lung fields. His peak expiratory flow rate is 60 L/min, and he is immediately started on an albuterol nebulizer and given IV hydrocortison
His arterial blood gas revealed a pH of 7.55, pCO2 of 21 mm Hg, and a pO2 of 60 mm Hg. Twenty minutes later, a repeat peak flow rate is still 60 L/min. A repeat arterial blood gas reveals that his pH is now 7.46, his pCO2 is now 34 mm Hg, and his pO2 is 64 mm Hg. Which of the following is the most appropriate next step in management?
A. Administer IV epinephrine
B. Administer 100% oxygen via a tight fitting face mask
C. Administer subcutaneous epinephrine
D. Prepare for intubation
E. Place a right thoracostomy tube
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| frontal
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B.
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| ARJ
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D. Prepare for intubation
Caution for everyone treating a case of Asthma
His respiration is failing not able to blow out the CO2.....One Should not be in false impression that he is improving with a little rise in O2..
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| frontal
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ARJ, note that the patient has low CO2 (and alkalosis) levels which are now approaching normalcy.
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| ARJ
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Thats the main point 21 low CO2 approaching Normancy 34 is an Ominous sign denoting that the RS is failing because of exhaustion.....Also the O2 rouse only by the unit of 4..............
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| frontal
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So the 'improvement' is deceptive. Hmm. Still, do you think one must intubate without giving o2 administration a try? 'B' hasn't yet been given a try like it should have, long back. Or so I think.
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| ARJ
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Hey, Phuluong whats the answer????
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| DrS
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The question doesent say oyxgen has been given in the case it should be B.( Administer 100% oxygen via a tight fitting face mask) before intubation I think
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| phuluong2k
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It is D, i will look for the explanation
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| phuluong2k
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D. This patient is having a very severe asthmatic attack, as demonstrated by his severe shortness of breath, use of accessory muscles of respiration, and variation in blood pressure with breathing (due to establishing a very negative intrathoracic pressure with forced attempts at inspiration). The initial pO2 is markedly decreased at 60 (compared to the normal 100) mm Hg. His pCO2 is also decreased at 21 mm Hg initially, due to "blowing off CO2" with his increased respirations while trying to get enough oxygen. This causes his respiratory alkalosis with pH 7.55. He is then treated, but the treatment improves his pO2 only slightly. Despite this, his pCO2 rises, and his pH returns toward normal. This does not mean he is getting better. Instead, we are seeing worsening respiratory failure as his ability to ventilate decreases, causing the inappropriate rise in pCO2 even though he is still very badly hypoxi
C. This patient should therefore be prepared for possible intubation if there is not immediate improvement.
Epinephrine (choices A and C) no longer is used in the management protocols of acute asthma because of its high rate of toxicity.
Administering 100% oxygen (choice B) may be an adjunctive therapy, but at this point the patient is probably saturating above 90% anyway.
There is no indication of a pneumothorax in this patient, so there is no need for a chest tube (choice E).
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| phuluong2k
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Another point, peak flow rate is still 60 l/m after treatment
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