Case study 1: Michael
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Michael's partner has called you to a campsite on his behalf following increased breathlessness and salbutamol inhaler usage with minimal effect. You are working as a double-crewed ambulance (DCA) with a non-qualified crewmember.
Michael is unable to speak full sentences and is positioned in a classic tripod appearance. Audible expiratory wheeze is present.
What further history and assessment would you want to make?
Select the headings for your findings
Further History
Presenting complaint: shortness of breath and difficulty breathing with audible wheeze.
History of presenting complaint: increasingly short of breath on minimal exertion, non-productive cough, increasing use of salbutamol inhaler with minimal positive effect.
Past medical history: asthma. Michael suffers with chronic asthma and is regularly required to utilise 999 services to manage his asthma condition. On 2 previous occasions, Michael has been admitted to the intensive case unit (ICU) for asthma care.
Drug history: salbutamol inhaler, Becotide inhaler.
Social history: lives with partner, non-smoker.
Family history: no significant history.
Allergies: none known.
Clinical Observations
Michael's observations are:
RR: 36 per minute
SpO2: 84% on air
HR: 116 beats per minute
BP: 158/94
temperature: 36.8C
GCS: 15/15
PEF: unable to record
NEWS (National Early Warning Score): 8 (prior to oxygen administration)
Question 1
What are your initial actions with this patient?
Select the correct option
Reassure, coach respirations, administer oral prednisolane
Incorrect. You should reassure, assess and administer salbutamol via a nebuliser.
Michael's current presentation classifies his condition as "severe" (PEF 33 to 50% of best predicted, RR >25bpm, HR >110bpm). Management should initially involve high levels of supplementary oxygen and nebulised salbutamol.
Reassure, assess, administer salbutamol via nebuliser.
Correct. You should reassure, assess and administer salbutamol via a nebuliser.
Reassure, assess, administer patients own inhaler
Incorrect. You should reassure, assess and administer salbutamol via a nebuliser.
Michael's current presentation classifies his condition as "severe" (PEF 33 to 50% of best predicted, RR >25bpm, HR >110bpm). Management should initially involve high levels of supplementary oxygen and nebulised salbutamol.
Reassure, gain a thorough history from patient's next of kin (NOK), assess
Incorrect. You should reassure, assess and administer salbutamol via a nebuliser.
Michael's current presentation classifies his condition as "severe" (PEF 33 to 50% of best predicted, RR >25bpm, HR >110bpm). Management should initially involve high levels of supplementary oxygen and nebulised salbutamol.
Assessment
This component is a flipcard comprised of flippable cards containing display image. Select the front face image to flip to the back face of these card to display associated text.
Select the images to reveal your assessment of Michael and his repeated observations.
Your assessment reveals:
inspection: visible increased RR, using accessory muscles
palpation: equal but shallow chest movement
percussion: unable to percuss as patient won't tolerate
auscultation: bilateral upper expiratory wheeze and decreased air entry to both lung bases
Repeated clinical observations:
RR: 40 per minute
SpO2: 82% on nebuliser
HR: 130 beats per minute
BP: 160/100
temperature: 36.8C
GCS: 13/15 (E=3, V=4, M=6)
PEF: unable to record
NEWS: 13
Question 2
This component is a multiple choice question. Once you have selected an option select the submit button below
What treatment should you initiate next?
Select the correct option
Facilitate transfer to ambulance for ongoing treatment
Correct. You should facilitate transfer to the ambulance for ongoing treatment.
Michael's observations are getting worse, despite first-line interventions. You have a conveyance resource; the patient should be moved to the ambulance for ongoing care and transfer to the nearest appropriate emergency department (ED)
Reassure, administer second dose of salbutamol and ipratropium bromide at the scene.
Incorrect. You should facilitate transfer to the ambulance for ongoing treatment.
Michael's observations are getting worse, despite first-line interventions. You have a conveyance resource; the patient should be moved to the ambulance for ongoing care and transfer to the nearest appropriate emergency department (ED).
A second dose of salbutamol and ipratropium bromide should be administered on route to hospital.
IM or IV hydrocortisone can be administered on route if available to your skill set.
Gain IV access, administer 100mg hydrocortisone on scene
Incorrect. You should facilitate transfer to the ambulance for ongoing treatment.
Michael's observations are getting worse, despite first-line interventions. You have a conveyance resource; the patient should be moved to the ambulance for ongoing care and transfer to the nearest appropriate emergency department (ED).
A second dose of salbutamol and ipratropium bromide should be administered on route to hospital.
IM or IV hydrocortisone can be administered on route if available to your skill set.
Wait 5 minutes to see if the nebuliser has been effective
Incorrect. You should be able to facilitate transfer to the ambulance for ongoing treatment.
Michael's observations are getting worse, despite first-line interventions. You have a conveyance resource; the patient should be moved to the ambulance for ongoing care and transfer to the nearest appropriate emergency department (ED).
A second dose of salbutamol and ipratropium bromide should be administered on route to hospital.
IM or IV hydrocortisone can be administered on route if available to your skill set.
Assessment
You are now on the ambulance. Michael is now extremely anxious and his breathing increasingly laboured. He is pallid, sweaty and his expiratory wheeze is now severe.
Repeated clinical observations:
RR: 50 per minute
SpO2: 76% on nebuliser
HR: 146 beats per minute
BP: unable to record as cuff won't work due to patient movement
temperature: 36.8C
GCS: 12/15 (E=3, V=3, M=6)
PEF: unable to record
NEWS: 16 (predicted)
Question 3
This component is a multiple choice question. Once you have selected an option select the submit button below
What is your management of Michael?
Select the correct option
Treat and facilitate immediate transfer to the nearest emergency department with pre-alert.
Correct. You should treat and facilitate immediate transfer to the nearest emergency department with pre-alert.
Despite interventions, both at scene and on the ambulance, Michael's condition is still worsening. He is showing no signs of improvement and he now has an altered level of consciousness despite treatment. His condition is now classified as "life threatening". With his history of previous admissions on an intensive care facility, rapid transfer is indicated to enable further critical care to be administered.
Treat and give non-conveyance advice
Incorrect. You should treat and facilitate immediate transfer to the nearest emergency department with pre-alert.
Despite interventions, both at scene and on the ambulance, Michael's condition is still worsening. He is showing no signs of improvement and he now has an altered level of consciousness despite treatment. His condition is now classified as "life threatening". With his history of previous admissions on an intensive care facility, rapid transfer is indicated to enable further critical care to be administered.
Treat and refer to own GP
Incorrect. You should treat and facilitate immediate transfer to the nearest emergency department with pre-alert.
Despite interventions, both at scene and on the ambulance, Michael's condition is still worsening. He is showing no signs of improvement and he now has an altered level of consciousness despite treatment. His condition is now classified as "life threatening". With his history of previous admissions on an intensive care facility, rapid transfer is indicated to enable further critical care to be administered.
Treat and refer to alternative care provider.
Incorrect. You should be able to facilitate transfer to the ambulance for ongoing treatment.
Michael's observations are getting worse, despite first-line interventions. You have a conveyance resource; the patient should be moved to the ambulance for ongoing care and transfer to the nearest appropriate emergency department (ED).
A second dose of salbutamol and ipratropium bromide should be administered on route to hospital.
IM or IV hydrocortisone can be administered on route if available to your skill set.
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