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43 Cards in this Set

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Mr A, a 75yo man who is a known patient of your practice and lives across the street presents anxious with oral pruritis, nausea, colicky abdominal pain and sudden onset SOB. This began within 5 minutes of eating some cashew nuts at home.
PMHx-major depression and panic disorder
Meds -Phenelzine(an irreversible MAO inhibitor)
Allergies -nil known

- Appearance - anxious and distressed man, pale, SOB with audible wheeze and early stridor, facial and neck oedema and urticaria
- Vital signs -afebrile, PR 120 reg, BP 80/?
- Chest - reduced air entry all areas, loud wheeze all areas, inspiratory stridor.

What is your provisional and differential diagnosis?
Provisional likely diagnosis:
- Anaphylaxis due to nut allergy.

DDx
- Upper airway obstruction from inhaled nuts.
- Asthma attack.
- Cardiac failure.
- Panic attack with hyperventilation.
- Vasovagal episode.
How do you manage a person coming in with anaphylaxis in general practice?
- Call 000 and order a category 2 ambulance transfer to hospital.
- Oxygen by mask 8L/min (be ready to intubate if required).
- Adrenaline 0.3mL of 1:1000 (=0.3mg) IMI - repeat every 3 minutes if effect incomplete (0.01mg/kg in children).
- IV access with large bore cannula (14 or 16g x 2).
- Treat hypotension with N/saline 20ml/kg bolus + repeat with further 10ml/kg boluses titrated to BP.
- Admision to hospital if biphasic reaction.
- Corticosteroid and antihistamines are not part of initial management (used later).
What is the most common allergen responsible for anaphylaxis?
Peanut.
What are common allergens responsible for anaphylaxis?
- Peanuts and tree nuts.
- Penicillin.
- Sulfurs.
- Cephalosporins.
- IV contrast.
- Aspirin and NSAIDs.
- Insect bites.
What percentage of patients presenting with anaphylaxis would have a history of known allergy?
30% (which is why history of previous allergy is NOT predictive of anaphylaxis).
What are the symptoms of anaphylaxis?
- Sudden onset severe bronchospasm with no previous history of asthma (though occurs in asthmatics also).
- Oral and pharyngeal pruritus.
- Cutaneous flushing, angioedema and urticaria.
- Sensation of tightening of airways.
- Colicky abdominal pain, nausea and vomiting.
- Progressive respiratory distress and stridor.
- Circulatory shock, hypotension and arrhythmias
rapidly progressive and not reversed by salbutamol.
How long does a patient with anaphylaxis require admission to hospital?
At least 12 hours, regardless of initial response. This is because a biphasic response is a possibility.
What percentage of anaphylactic patients will have a biphasic response?
20% will have return of bronchospasm within 12 hours. It is often severe and refractory to treatment and not redictable which patients this will occur to.
What treatment would a biphasic reaction often require?
- Intubation and ventilation with high ventilatory pressures due to severe bronchospasm.
- Corticosteroids (methylprednisolone) and antihistamines (promethazine)are given at hospital as secondary management to attempt to minimise this reaction.
How would a GP follow-up a patient who had an anaphylactic attack?
- Identify and avoid the allergen.
- Refer to allergist or immunologist.
- Educate patient and family on adrenaline administration (Epipen and Epipen Junior).
- Educate patient and family on signs and symptoms of anaphylaxis.
- Medical warning bracelet and always carry and keep in date Epipen.
What is the emergency management plan of a patient coming in with a severe exacerbation of asthma?
- Dial 000, order a category 2 ambulance transfer to hospital (get receptionist to do this).
- Oxygen 8L/min via nebuliser mask.
- Continuous 5mg salbutamol nebulisers.
- Single dose ipratropium 500mcg in 1st nebuliser only.
- Obtain IV access and hydrocortisone 250mg IVI (or 4mg/kg).
- Consider IM adrenaline if respiratory failure and nto responding to nebulised salbutamol (IV salbutamol in hospital).
What are the risk factors for severe asthma?
- Previous intensive care admission for asthma
- History of rapid onset and poorly responsive asthma
- Frequent hospital admissions or oral steroid use
- Poor response to treatment of current exacerbation
- Psychosocial instability
- Poor comprehension or poor compliance
- Children under 5yo
What are the symptoms of a severe asthmatic attack?
- use of accessory muscles
– talking in words only
– pulse rate >120
– palpable pulsus paradoxus
– central cyanosis
– “quiet”chest
– PEFR <50% or <100 L/min
– pulse oximetry <92%
Should there be any changes in treatment of pregnant women with a severe asthma attack than a non-pregnant woman?
No, because foetal hypoxia is far more dangerous than any issues that the drugs might or might not cause.
What concern is there with the presence of ventricular ectopics?
It's a potential precursor to ventricular fibrillation.
How would you manage a patient coming into general practice with an MI?
- Dial “000”and order category 2 ambulance transfer to hospital (get your receptionist to organise).
- Oxygen via mask at 8L/min.
- Aspirin 300mg soluble orally (unless anaphylaxis).
- Glyceryl Trinitrate spray under tongue every 2 mins.
- IV access for safety and ?drug administration.
- IV metoclopramide10mg
- IV morphine 1-2mg/min -for pain relief and decrease circulating catecholamines which stimulate arrythmias.
- Be ready to treat arrythmias(??lignocaine).
- Be ready for arrest and know CPR/BLS.
- Early defibrillation if VF/pulseless VT.
What differentiates a vasovagal episode from anaphylaxis?
Vasovagal episodes respond promptly to a recumbent pose while the symptoms of anaphylaxis are progressive.
Cutaneous symptoms are present in what percentage of anaphylaxis?
90%.
Rapid onset of hypotension in anaphylaxis might mask the appearance of _____, which may only occur transiently once adrenaline is administered.
Urticaria.
What are the initial energy levels for the first 3 shocks in defibrillation of VF or pulseless VT?
200J, 200J, 360J. Subsequent shocks at 360.
How do biphasic defibrillators work?
Delivers their waveform in two directions, with the second wave reversing the direction.
What are the advantages of using biphasic defibrillation?
- Reduced energy requirements used for the units required (150J).
- Reduced cardiac damage as a result, resulting in a decrease in postshock cardiac dysfunction.
- Smaller and less expensive.
After initial 3 shocks of defibrillation of VF/VT, what should you do?
- Continue cardiopulmonary resuscitation.
- Reassess cardiac rhythm at 1-minute intervals.
- Adrenaline may be considered (1mg in adults).
-
How is adrenaline supposed to help in cardiac arrest?
Works mainly via maintaining coronary artery perfusion by alpha-receptor stimulation rather than as a direct cardiac stimulant.

Improved coronary perfusion
is thought to be more conducive to effective
ventricular defibrillation.
Adrenaline alone has not been demonstrated to be associated with improved outcome.
If IV access cannot be obtained during cardiac arrest, how could you give adrenaline?
Endotracheally. The dose in this setting is 2-3 times more.
What anti-arrhythmic drugs may be tried if VF/VT is refractory to defibrillation and adrenaline?
- Lignocaine.
- Amiodarone (better than lignocaine).
What should amiodarone be reconstituted with before using in VF/VT?
Amiodarone needs to be reconstituted with dextrose, ideally in a glass syringe as it adheres to plastic.
Other than IHD, what other possible causes of cardiac arrest would you need to consider?
- Hypomagnesaemia.
- TCA overdose (sodium bicarbonate).
What is the success rate for resuscitating a patient with asystole/pulseless electrical activity?
It approaches zero.

:(
Tachycardia or
bradycardic pulseless electrical activity should
prompt the treating health care provider to quickly...
Assess for the potentially reversible causes.

Interventions directed at these reversible causes
should be undertaken in parallel with the cardiac
arrest algorithms.

Adrenaline at a dose of 1 mg is administered every three minutes of continuous CPR. The patient must be reassessed for vital signs and rhythm change at this time.
What is the rapid discontinuation criteria for ambulance CPR?
- Complete absence of any signs of life (including no respiratory effort), AND
- Flatline asystole on ECG (in at least 2 leads), AND
- A history of at least 10 minutes pulseless and unresponsive with no CPR.

If in doubt, continue CPR
Severe asthma and hypoxia can cause what to the heart rate?
Bradycardia.
What might you think of if a patient presenting with a severe asthma attack started to have less audible wheezing?
Patient might be tiring, resulting in a reduction in volume of ventilation.
What is pulsus paradoxus?
It may occur in a severe asthma attack.

Changes in systolic blood pressure that results from dramatic swings in intrathoracic pressure which are required to overcome the increased ventilatory resistance of asthma.

Normally there is less than 10 mmHg difference
in systolic pressure between inspiration
and expiration, but this can exceed 40 mmHg in
severe asthma. Importantly, if the patient fatigues
and the respiratory effort declines, the pulsus paradoxus
may also decline.
What haemoglobin oxygen saturation (using pulse oximetry) is a good indication of moderate to severe asthma?
95%.
What haemoglobin oxygen saturation (using pulse oximetry) is a good indication of moderate to severe asthma?
95%.
How can use of bronchodilators worsen a patient's hypoxia (which is why you should use it in conjunction with oxygen) in a severe asthma attack?
The use of bronchodilators can cause pulmonary
vasodilation and this can result in increased blood
flow to areas of poorly ventilated lung. This change
in pulmonary blood flow caused by the bronchodilators,
increases pulmonary ‘shunting’ and
this can worsen the patient’s hypoxia.
In life-threatening asthma, should you use a nebuliser or a metered dose inhaler with a spacer?
Nebuliser: patients respond better to continuous
nebulised bronchodilator therapy than to intermittent
treatment.

For a patient with severe asthma 5 mg of salbutamol (2.5 mg for a child) should be added to the nebuliser every few minutes to ensure there is a continuous supply of bronchodilator.
How much salbutamol should you use to treat a severe asthma attack?

How long do you use it for?

What else should you use in addition to the first dose of salbutamol?
For a patient with severe asthma 5 mg of salbutamol (2.5 mg for a child) should be
added to the nebuliser every few minutes to ensure there is a continuous supply of bronchodilator.

Response to therapy should be re-evaluated after 20-30 minutes.

A single dose of 500 μg nebulised ipratropium bromide (250 μg in children) should be given with the first dose of salbutamol.
What is the best way to administer steroids in a severe asthma attack?
Inhaled steroids are thought to be just as effective as oral steroids in the treatment of mild and moderate asthma.

However, in cases of severe asthma systemic steroids are normally preferred over inhaled steroids.
In severe life-threatening asthma, why would intravenous steroids be more beneficial than oral steroids?
Gastric absorption may be decreased.
Parenteral adrenaline is extremely effective in the
treatment of severe life threatening asthma. However, it is also a high risk intervention. Risk factors for increased side effects of adrenaline are:
- Over 50 years of age.
- History of coronary artery disease.
- Arrhythmias or uncontrolled hypertension.
When should adrenaline be used for severe asthma?
Adrenaline should be reserved for the most severe cases not responding to continuous nebulised salbutamol with oxygen and intravenous corticosteroids.

As a rule adrenaline should only be given while the patient is on a cardiac monitor.

However, when confronted by an emergency in GP where no monitor is available, if the patient is in extremis then SC adrenaline should be considered.