Simulation case | A 29 year old with sudden onset breathlessness

Examination

Dwane is talking but has stridor and is unable to speak in full sentences.

He is extremely agitated.

Students should recognise the acute airway issue and have a high suspicion for antibiotic-induced anaphylaxis from tonsillitis treatment.

At this stage, they should also consider the tonsillitis (? peritonsillar abscess) as a possible cause.

Investigations

Students can look in the patient’s mouth - visible angioedema.

They should NOT attempt to examine the throat (i.e. with a tongue depressor or other instrument) as this can precipitate further airway oedema.

Interventions

Call for help urgently – ED senior/anaesthetist

Assess ability to maintain airway. Consider use of adjuncts. Ensure equipment is ready for RSI

Recognise the antibiotic that is running and STOP the IV infusion immediately

IM 0.5mg Adrenaline 1:1000 to the anterolateral thigh

Examination

RR: 20, SpO2: 91%

Chest expansion – normal and equal.

Percussion - normal resonance.

Auscultation - reduced air entry bilaterally, struggling to hear anything over the stridor and wheeze.

Investigations

Anaphylaxis is a clinical diagnosis. But students may wish to order tests to rule out other causes.

Students may ask for:

• ABG
• CXR
• Neck CT for ? peritonsillar abscess – if they request this, patient is currently too unstable to transfer

Interventions

Recognise hypoxia

• Give oxygen – 15L/min via NRB – can titrate down based on patient response
• Sitting the patient more upright may assist with ventilation

Once 5 mins has elapsed, can give a second dose of adrenaline, this can be repeated every 5 mins depending on response.

Examination

HR 115, BP 89/66, Temp 37.6C

Pulse is fast, regular, but feels weak

CRT 3 seconds

HS I + II + 0

No peripheral oedema

Dwane looks flushed

He has one cannula already inserted

Investigations

Insert another cannula – 14G (Orange) or 16G (Grey)

Bloods – ask to justify:

• FBC – ?infection
• U&Es – renal function and electrolyte depletion
• LFTs – liver function for medications
• CRP – ?infection
• Mast cell tryptase – supports diagnosis of anaphylaxis

Consider 'sepsis six' screen given the patient's infection history

ECG as a baseline, and for monitoring the effect of adrenaline

Interventions

Patient is severely hypotensive

• 500-1000 ml resus bolus STAT of crystalloid (NaCl or Hartmann’s)
• Anaphylaxis patients can often require up to 3-5L of fluid

Dwane has a temperature, but said he already had a fever due to the tonsillitis – something to keep an eye on

Examination

Alert but very agitated

GCS 15/15

PEARL

Investigations

Bedside CBG – 4.8 mmol/L

Interventions

None required.

Examination

Dwane’s face is flushed

Angioedema

Abdomen SNT

Calves SNT

No peripheral oedema

Mottling/urticaria to the arms and legs

Investigations

None required.

Interventions

If students feel treatment is not working, can consider:

• Nebulised adrenaline
• IV adrenaline infusion
• Bronchodilators
• Antihistamines and steroids
• RSI with ketamine and ICU transfer