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  1. #1
    Statia Graduate is offline Junior Member 510 points
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    Another case for you...

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    I'll be more specific with this one:

    23 year-old white female with long-standing history of uncontrolled asthma arrives to the ER by EMS. A family member called 911 when the patient kept complaining of SOB and stating that her inhalers weren't working anymore. When she arrives, she is in moderate distress, she is diaphoretic and tachypnic and unable to complete sentences. She is sitting up on the gurney, leaning forward with pursed lips. She is using accessory muscles to breath.

    Vitals:
    145/98, HR: 124, RR: 36, temp: 97.6, O2: 93% on 100% nonrebreather

    Physical Exam (I'll stick to the system involved):
    Heart: Tachy, regular, no murmurs, rubs, or gallops
    Lungs: Accessory muscle use, nasal flaring, pursed lips, a few scattered soft exp wheezes

    ABG reveals:
    pH: 7.38, PCO2: 42, PO2: 105

    pCXR shows hyperinflated lungs

    Other labs are pending, because well, in the real world, the ABG comes back first!

    So, what should you do next?

    A. albuterol and atrovent nebs
    B. place on Bipap
    C. albuterol and atrovent nebs, solumedrol, magnesium
    D. treat with nebs and send for CT chest
    E. intubate

  2. #2
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    I would do A and see how she does. then i'd give her some steriods if A didn't help.

    I guess they called the EMS and the EMS got there pretty quick cause he ABG is normal. if she's breathing at 36 you'd expect her pH to be a little higher and PCO2 a little lower.

    she doesn't need Bipap, or intubation cause she's still saturating above 90%. why would you get a CT scan? do you think she has a PE?
    Hollywood Upstairs School of Medicology, Class of 2010
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  3. #3
    Statia Graduate is offline Junior Member 510 points
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    So close!

    So close! You are right, the ABG is normal!

    That is the clue in this case. Her ABG should be no where near normal. She is very tachypnic, so she should have respiratory alkalosis. The PCO2 should be much lower than normal. So, she has respiratory failure.

    The other clue is the CXR. An asthmatic's CXR should be stone-cold normal. Hyperinflation is a red flag.

    Also, the PE is describes as a few, soft exp wheezes. Another red flag. To not hear wheezes means that she is not moving air.

    So, the answer to the question is E.

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    Chopdoc is offline Senior Member 528 points
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    Quote Originally Posted by RussianJoo View Post
    I would do A and see how she does. then i'd give her some steriods if A didn't help.

    I guess they called the EMS and the EMS got there pretty quick cause he ABG is normal. if she's breathing at 36 you'd expect her pH to be a little higher and PCO2 a little lower.

    she doesn't need Bipap, or intubation cause she's still saturating above 90%. why would you get a CT scan? do you think she has a PE?
    Have another look, given the presentation the normalization of the ABGs is a sign of progression through stage III or crossover.

    She's in trouble.

    Tube her.

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    Quote Originally Posted by Statia Graduate View Post
    So close! You are right, the ABG is normal!

    That is the clue in this case. Her ABG should be no where near normal. She is very tachypnic, so she should have respiratory alkalosis. The PCO2 should be much lower than normal. So, she has respiratory failure.

    The other clue is the CXR. An asthmatic's CXR should be stone-cold normal. Hyperinflation is a red flag.

    Also, the PE is describes as a few, soft exp wheezes. Another red flag. To not hear wheezes means that she is not moving air.

    So, the answer to the question is E.
    I was busy typing my answer when you posted this!

    This is a great question and far too many people get nailed on it.

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    I thought since Asthma is an obstructive disease you will see some hyperinflation of the lungs? like you do with COPD.
    Hollywood Upstairs School of Medicology, Class of 2010
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    Quote Originally Posted by Chopdoc View Post
    Have another look, given the presentation the normalization of the ABGs is a sign of progression through stage III or crossover.

    She's in trouble.

    Tube her.
    I am not familiar with stage III and cross over do you mean stage III asthma? how do you stage asthma? I thought it was staged mild moderate severe, based on how many day time and night time attacks you have.

    Could you please go over the stages you're talking about and what you mean by crossover?
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  8. #8
    Statia Graduate is offline Junior Member 510 points
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    Quote Originally Posted by Chopdoc View Post
    I was busy typing my answer when you posted this!

    This is a great question and far too many people get nailed on it.
    Thanks, I have many more. But I must get STarbucks first!

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    Quote Originally Posted by RussianJoo View Post
    I am not familiar with stage III and cross over do you mean stage III asthma? how do you stage asthma? I thought it was staged mild moderate severe, based on how many day time and night time attacks you have.

    Could you please go over the stages you're talking about and what you mean by crossover?
    Well, I'm no expert, and I don't know if in fact this system of classification is used, but I learned it at some point....
    Four stages: mild attack or chronic/stable, mild to moderate attack, crossover, and severe.

    Crossover is the point at which the progressing acidosis and hypercapnia cross on the superimposed graphs, beyond this point the patient is in a severe attack. A patient can progress through crossover very quickly so it is important to understand that normalization of the ABGs is really just a point in a progression toward a life threatening state of respiratory failure.

    Regardless of how one graphs it or breaks it down into stages the important thing is to note and understand the clinical presentation of a patient clearly in the advanced stages of an asthma attack that is progressively worsening.
    When she arrives, she is in moderate distress, she is diaphoretic and tachypnic and unable to complete sentences. She is sitting up on the gurney, leaning forward with pursed lips. She is using accessory muscles to breath.
    The normalization of the ABGs is a bad thing at such a point.

    This patient is working very hard just to breath and is going to get tired very quickly.

    She isn't moving much air at this point as evidenced by the physical exam findings:
    Accessory muscle use, nasal flaring, pursed lips, a few scattered soft exp wheezes
    Of course, the CXR demonstrates hyperinflation.

  10. #10
    RussianJoo's Avatar
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    thank you so much for the explanation.
    Hollywood Upstairs School of Medicology, Class of 2010
    Due to the high volume of private messages, I can only answer questions that are posted in a forum. Private messages will be ignored.
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