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Yr 4 - OSCE Stations > ABCDE: Anaphylaxis, Acute Asthma, & COPD Exacerbation > Flashcards

ABCDE: Anaphylaxis, Acute Asthma, & COPD Exacerbation Flashcards

1
Q

Key symptoms in anaphylaxis?

A
  • A feeling of the throat closing up
  • Dyspnoea
  • Chest tightness
  • Nausea and vomiting
  • Abdominal pain (especially if caused by food allergies)
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2
Q

What airway problems may be seen in anaphylaxis?

A
  • Difficulty in breathing and/or swallowing
  • Hoarse voice
  • Stridor
  • Swollen tongue and lips +/- saliva drooling
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3
Q

What breathing problems may be seen in anaphylaxis?

A
  • Dyspnoea and tachypnoea
  • Wheeze (widespread)
  • Cyanosis
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4
Q

What circulation problems may be seen in anaphylaxis?

A
  • Tachycardia: typically a rapid, weak, thready peripheral pulse
  • Hypotension
  • Cold, clammy skin with prolonged CRT
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5
Q

What skin and/or mucosal changes may be seen in anaphylaxis?

A
  • Widespread urticarial/erythematous rash
  • Generalised pruritus
  • Angioedema
  • Flushing
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6
Q

The onset and the primarily affected organ system can vary depending on the trigger of anaphylaxis.

Describe onset and primarily affected organ system (i.e. breathing or circulation) for anaphylaxis caused by:

1) Food
2) Medication
3) Insect sting

A

1) Less rapid onset, breathing problems typically predominate

2) Rapid onset, circulation problems typically predominate

3) Rapid onset, circulation problems typically predominate

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7
Q

What are some common causes of sudden onset SOB?

A

1) Foreign body aspiration

2) Acute epiglottitis (in a child)

3) Acute exacerbation of asthma or COPD

4) PE

5) Pneumothorax

6) Panic attack

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8
Q

What is oral allergy syndrome?

A

A type I hypersensitivity reaction initiated by cross-reaction with a non-food allergen, such as pollen or latex, involving plant-based foods only.

Unlike anaphylaxis, it usually only causes oropharyngeal symptoms like itching and a tingling sensation, with or without mild swelling of the lips and tongue.

Symptoms tend to fully resolve within one hour post-contact and rarely develop into anaphylaxis, although it is sometimes possible.

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9
Q

What are some other causes of skin rashes or cutaneous flushing?

A

1) carcinoid syndrome

2) red neck syndrome (from rapid vancomycin infusion)

3) scombroid food poisoning (from contaminated fish)

4) monosodium glutamate poisoning

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10
Q

Assessment, investigations & management of ‘breathing’ in anaphylaxis?

A

Assessment: RR, O2, signs of respiratory distress, central cyanosis, trachea position, expansion, auscultation & percussion.

Investigations: ABG, CXR

Management: O2 therapy, can give nebulised salbutamol if wheeze is present (bronchospasm).

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11
Q

Assessment, investigations & management of ‘circulation’ in anaphylaxis?

A

Assessment: HR & character, BP, temp, CRT, JVP, fluid status, auscultation.

Insert 2x wide bore cannulae.

Investigations: bloods (FBC, U&Es, LFTs, coagulation, CRP, serum tryptase), ECG.

Management: fluid bolus if hypotensive (500ml 0.9% saline over 15 mins), IM adrenaline (1:1000)

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12
Q

What is the 1st line treatment for anaphylaxis?

A

IM 0.5ml adrenaline 1:1000.

Repeat every 5 minutes.

If no improvement after 2 administrations –> consider IV adrenaline infusion (expert input).

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13
Q

If patient with anaphylaxis has a wheeze, what can be considered?

A

Nebulised salbutamol +/- nebulised ipratropium bromide (500mcg)

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14
Q

Purpose of ECG in anaphylaxis?

A

To look for evidence of acute myocardial ischaemia, which may occur secondary to anaphylaxis.

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15
Q

What dose of IM adrenaline is given for an adult with anaphylaxis?

A

0.50ml of 1:1000 adrenaline

Repeat every 5 mins as necessary

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16
Q

When is a serum mast cell tryptase recommended in anaphylaxis?

A

1) Where diagnosis is uncertain

2) In children <16 if the cause is thought to be venom-related, drug-related, or idiopathic

Although an elevated serum mast cell tryptase level confirms the diagnosis of anaphylaxis, a normal result does not rule out anaphylaxis.

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17
Q

Dosing of adrenaline in ALS vs anaphylaxis for adults?

A

ALS –> IV or IO 10ml (1mg) of 1:10,000

Anaphylaxis –> IM 0.5ml (500 micrograms) of 1:1000

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18
Q

Assessment & investigations in ‘disability’ in anaphylaxis?

A

AVPU
Pupils
Temp
Drug chart review
Glucose & ketones

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19
Q

Once the patient has been stabilised in anaphylaxis, what medication can be offered?

A

Non-sedating oral antihistamines (e.g. cetirizine) - to treat skin symptoms.

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20
Q

Clinical features of acute asthma?

A
  • Shortness of breath
  • Wheeze
  • Tachypnoea
  • Hypoxia
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21
Q

PEFR in moderate vs severe vs life-threatening asthma exacerbation

A

Moderate: >50-70% of best or predicted

Severe: 33-50%

Life-threatening: <33%

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22
Q

What defines a near-fatal asthma exacerbation?

A

Raised PaCO2 and/or requiring mechanical ventilation with raised inflation pressures.

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23
Q

What category of asthma exacerbation is O2 sats <92%?

A

Life-threatening

24
Q

What category of asthma exacerbation is HR ≥110?

A

Severe

25
Q

Assessment, investigations & management of ‘breathing’ in acute asthma?

A

Assessment: O2, RR, signs of distress, cyanosis, trachea position, expansion, auscultation, percussion

Investigations: ABG, PEFR, CXR

Interventions: SIT PATIENT UP! O2 therapy, nebuliased salbutamol, steroid therapy, ipratropium bromide, consider magnesium sulphate, consider IV aminophylline

26
Q

Purpose of PEFR in acute asthma?

A

PEFR can be used to assess the severity of the patient’s asthma exacerbation and their subsequent response to treatment.

However, PEFR recording shouldn’t delay the administration of oxygen and nebulised medications.

27
Q

1st line treatmnet in management of acute asthma?

A

A high-dose inhaled beta-2 agonist (i.e. salbutamol)

28
Q

How is salbutamol delivered in mild/mod, severe vs life-threatening asthma?

A

Mild/mod: use either pressurised multiple-dose inhaler (pMDI) plus spacer or oxygen-driven nebulisation to administer salbutamol.

Severe: use oxygen-driven nebulisation to administer salbutamol.

Life-threatening: use continuous oxygen-driven nebulisation to administer salbutamol.

29
Q

How often should doses of salbutamol be repeated in acute asthma?

A

Repeat at 15-30 min intervals

or

Give continuous nebulised salbutamol at 5-10 mg/hour if there is an inadequate response to initial treatment.

30
Q

How can salbutamol be given if there is an inadequate response to initial treatment?

A

Can be given continuously at 5-10mg/hour

31
Q

1st line management of acute asthma?

A

1) Nebulised salbutamol

2) Oral prednisolone / IV hydrocortisone (if oral route unavailable)

3) Add nebulised ipratropium bromide if severe or life-threatening asthma (or those with a poor initial response to beta-2 agonist therapy)

32
Q

What dose of oral prednisolone is given in acute asthma?

A

40-50mg

33
Q

How long is oral prednisolone continued for following an asthma attack?

A

at least 5 days after exacerbation or until recovery

34
Q

Who should nebulised ipratropium bromide given to in acute asthma?

A

1) severe or life-threatening asthma

2) poor initial response to beta-2 agonist therapy

35
Q

Dose of ipratropium bromide given in acute asthma?

A

0.5mg 4-6 hourly

36
Q

In patients with life-threatening/near-fatal asthma who are not responding to intial therapy, what 2 medications can be considered?

A

1) IV magnesium sulphate (single dose)

2) IV aminophylline

These should only be used following consultation with senior medical staff.

37
Q

What additional investigation may be useful under ‘breathing’ in COPD exacerbation?

A

Sputum culture - useful later to understand the causative organism and its antibiotic sensitivities.

38
Q

1st line management of COPD exacerbation?

A

1) Nebulised salbutamol

2) Nebulised iratropium bromide 500 micrograms (if patient does not respond adequately to nebulised salbutamol)

3) Steroids (ALL patients) –> oral prednisolone 30mg once a day for 5 days

39
Q

How should salbutamol be given in COPD exacerbation if the patient is hypercapnic or acidotic?

A

Driven by compressed air rather than oxygen (to avoid worsening hypercapnia).

40
Q

How often should doses of salbutamol be repeated in COPD exacerbation?

A

At 15-30 min intervals, or give continuous nebulised salbutamol at 5-10 mg/hour.

41
Q

When shuld ipratropium bromide be given in COPD exacerbation?

A

If the patient does not respond adequately to nebulised salbutamol.

42
Q

Dose of ipratropium bromide given in COPD exacerbation?

A

500 micrograms

43
Q

How is ipratropium bromide given in COPD exacerbation?

A

Ipratropium bromide can be given with salbutamol in the same nebuliser.

44
Q

What dose of oral prednisolone is given in COPD exacerbation?

A

30mg daily for 5 days

45
Q

If 1st line interventions fail in COPD exacerbation, what should you do?

A

Escalate care.

Consider:
1) NIV for persistent hypercapnic respiratory failure.
2) Respiratory stimulants and intravenous theophylline.

46
Q

Typical signs & symptoms of pulmonary oedema?

A

Symptoms:
- SOB
- Pink frothy sputum

Signs:
- Tachypnoea
- Decreased O2 sats
- Raised JVP

47
Q

What 2 investigations are indicated in ‘breathing’ in pulmonary oedema?

A

1) ABG
2) CXR

48
Q

What CXR features may be seen in pulmonary oedema?

A

1) Bilateral peri-hilar shadowing

2) Blunting of the costophrenic angles

3) Fluid in the fissures (e.g. right horizontal fissure)

4) Kerley B lines

49
Q

Interventions in ‘breathing’ in pulmonary oedema?

A

1) Sit patient up

2) O2: non-rebreathe mask with an oxygen flow rate of 15L

50
Q

What bloods may be useful in pulmonary oedema?

A

1) FBC
2) U&Es
3) LFTs
4) CRP
5) Troponin
6) Plasma BNP

51
Q

Investigations & interventions in ‘circulation’ of pulmonary oedema?

A

Investigations:
- ECG
- Bloods from cannula

Interventions:
- Diuretics

52
Q

What is an ECG looking for in pulmonary oedema?

A
  • evidence of acute myocardial ischaemia
  • ventricular hypertrophy
  • arrhythmias
53
Q

What is the mainstay of management of pulmonary oedema?

A

1) Sit patient up

2) O2 therapy

3) IV loop diuretics e.g. furosemide

54
Q

What intervention is considered for patients with pulmonary oedema who do not improve after supplemental oxygen and IV diuretics?

A

CPAP

55
Q

Who should loop diuretics be used with caution in in pulmonary oedema?

A

Hypotensive patients –> therefore critical care input should be sought

56
Q
A

Yr 4 - OSCE Stations (17 decks)

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