EM Cases

Question 1

Asthma Exacerbation Case

Answer 1

35yof presents in respiratory distress. speaking 1-3 word sentences.

Onset: 3 hours ago

complaints: shortness of breath, no chest pain, no other s/s

h/o asthma with prior intubations, no allergies

VS: HR 120 Sinus, BP 110/80, R 35, 98%, T 37 (make them ask for temp specifically)

PE: resp distress, wheezing present diffusely, no rashes, no trauma, no fever

Intern level critical interventions:

1. albuterol nebulizer
2. magnesium 2g over 30mins IV
3. either methylprednisolone 125mg or dexamethasone 16mg IV
   
   • • after the above interventions patient continues to have obvious respiratory distress
4. epinephrine 0.3mg IM
   
   • improves patient’s bronchospasm slightly, patient initially starts moving more air but then on reassessment, patient’s respiratory rate has slowed and the lungs still are with diffuse wheezing.
5. BIPAP 12/5
   
   • -intern: patient tolerates BIPAP well and improves. Case ends.
   • -second year and above: patient initially tolerates BIPAP then becomes obtunded and tries to rip it off critical labs to obtain: VBG, CXR/US, ekg, CBC, BMP, UA, urine preg intern

discussion points:

• most common cause of asthma exacerbation […]
• relevant pathophys of asthma, i.e. unable to effectively exhale, not a problem with oxygenation
• VBG interpretation - how to tell if tiring out
• BIPAP settings

2nd year resident level critical interventions:

1. terbutaline 0.25mg SC
2. repeat VBG
3. intubation based on VBG
   
   • ketamine and awake if possible
4. proper vent settings (low TV and rate, decrease I:E ratio)

discussion points:

• intubation meds for asthma
• how to do awake intubation:

3rd year resident level critical interventions:

1. vent management when condition worsens
2. asthma literature…

Question 2

Aortic Dissection Case