Staff Zone - Emma

Case study 2: Emma

You are working as ambulance crew covering a running race in a country park.

You are based at the event medical tent when you are presented with Emma who has been brought to you by one of the first responders.

Emma has walked to the medical facility and is able to communicate that she has been competing in the running race; she has completed approximately 3km (of a 5km race) when she has become "unable to get her breath". She has her salbutamol inhaler with her.

What further history and assessment would you want to make?

Further History

Presenting complaint: shortness of breath.
History of presenting complaint: complaining of SOB of during exercise.
Past medical history: asthma.
Drug history: salbutamol inhaler (rarely uses).
Social history: lives with friend, non-smoker, active at sports.
Family history: no significant history
Allergies: none

Clinical Observations

Emma's observations are:

RR: 22 per minute
SpO2: 94% on air
HR: 100 beats per minute
BP: 134/84
temperature: 37.4C
GCS: 15/15
PEF: 350
NEWS: 4

Question 1

What are your initial actions with this patient?

Select the correct option

Reassure, coach respirations, consider (and treat) for anxiety episode

Incorrect. You should reassure, assess and administer the patient's own inhaler.

Emma's current presentation classifies her condition as "mild to moderate" (increasing symptoms, PEF >50 to 75% best or predicted, no features of acute severe asthma), she is able to communicate her history of presentation and able to administer her inhaler.

Increase the dose by 2 puffs every 2 minutes, according to response, up to 10 puffs. If symptoms are not controlled by 10 puffs, then nebulised salbutamol should be started.

Reassure, assess, and administer patient's own inhaler

Correct. You should reassure, assess and administer the patient's own inhaler.

Reassure, and administer both salbutamol and ipratropium nebuliser

Incorrect. You should reassure, assess and administer the patient's own inhaler.

Emma's current presentation classifies her condition as "mild to moderate" (increasing symptoms, PEF >50 to 75% best or predicted, no features of acute severe asthma), she is able to communicate her history of presentation and able to administer her inhaler.

Increase the dose by 2 puffs every 2 minutes, according to response, up to 10 puffs. If symptoms are not controlled by 10 puffs, then nebulised salbutamol should be started.

Adrenaline

Incorrect. You should reassure, assess and administer the patient's own inhaler.

Emma's current presentation classifies her condition as "mild to moderate" (increasing symptoms, PEF >50 to 75% best or predicted, no features of acute severe asthma), she is able to communicate her history of presentation and able to administer her inhaler.

Increase the dose by 2 puffs every 2 minutes, according to response, up to 10 puffs. If symptoms are not controlled by 10 puffs, then nebulised salbutamol should be started.

Assessment

You administer 10 puffs of salbutamol and continue your assessment.

Select the images to reveal your assessment of Emma and her repeated observations.

Your assessment reveals:

inspection: visible increased RR, no use of accessory muscles
palpation: equal but shallow chest movement
percussion: equal resonance
auscultation: bilateral widespread expiratory wheeze

Repeated clinical observations:

RR: 20 per minute
SpO2: 94% on air
HR: 96 beats per minute
BP: 128/90
temperature: 37.3C
GCS: 15
PEF: 360
NEWS: 2

Question 2

What treatment should you initiate next?

Select the correct option

Request an ambulance via 999 to take to hospital.

Incorrect. You should administer salbutamol via nebuliser.

Emma's observations have slightly improved. However, following auscultation, there is still a bilateral widespread expiratory wheeze.

Without a spacer to aid the inhaler, it is difficult to inhale the salbutamol. Nebulised administration is a more effective route.

Administer salbutamol via nebuliser

Correct. You should administer salbutamol via nebuliser.

Emma's observations have slightly improved. However, following auscultation, there is still a bilateral widespread expiratory wheeze. Without a spacer to aid the inhaler, it is difficult to inhale the salbutamol. Nebulised administration is a more effective route.

Gain IV access, and administer 100mg hydrocortisone on scene.

Incorrect. You should administer salbutamol via nebuliser.

Emma's observations have slightly improved. However, following auscultation, there is still a bilateral widespread expiratory wheeze.

Without a spacer to aid the inhaler, it is difficult to inhale the salbutamol. Nebulised administration is a more effective route.

Continue with further inhaler use

Incorrect. You should administer salbutamol via nebuliser.

Emma's observations have slightly improved. However, following auscultation, there is still a bilateral widespread expiratory wheeze.

Without a spacer to aid the inhaler, it is difficult to inhale the salbutamol. Nebulised administration is a more effective route.

Assessment

Emma is now more relaxed, she is able to communicate verbally without any concerns, her observations are as stated. She expresses that she does not wish to go to hospital and would prefer to go home with her friend.

Repeated clinical observations:

RR: 16 per minute
SpO2: 99% on nebuliser
HR: 88 beats per minute
BP: 126/84
temperature: 36.8C
GCS: 15
PEF: 540
NEWS: 0

Question 3

What is your management of this patient?

Select the correct option

Treat and give non-conveyance advice and appropriate paperwork (as per procedures).

Correct. You should treat and give non-conveyance advice and paperwork.

Following your interventions, Emma has responded well to treatment. Her observations have returned to normal parameters and she is going home with her friend so she has an appropriate safety net. Appropriate records and paperwork should be completed and shared, as per local procedures.

Treat and refer to patient's own GP

Incorrect. You should treat and give non-conveyance advice and paperwork.

Following your interventions, Emma has responded well to treatment. Her observations have returned to normal parameters and she is going home with her friend so she has an appropriate safety net. Appropriate records and paperwork should be completed and shared, as per local procedures.

Treat and refer to an alternative care provider.

Incorrect. You should treat and give non-conveyance advice and paperwork.

Following your interventions, Emma has responded well to treatment. Her observations have returned to normal parameters and she is going home with her friend so she has an appropriate safety net. Appropriate records and paperwork should be completed and shared, as per local procedures..

Treat and transfer to nearest A+E

Incorrect. You should treat and give non-conveyance advice and paperwork.

Following your interventions, Emma has responded well to treatment. Her observations have returned to normal parameters and she is going home with her friend so she has an appropriate safety net. Appropriate records and paperwork should be completed and shared, as per local procedures.