Simulation case | A 29 year old with sudden onset breathlessness

James Hobson   Published 10th February 2023

Handover from ED healthcare assistant

Dwane Blake-Watkins - 29yr old male attended this evening with severe throat pain, difficulty swallowing and pyrexia. Reviewed by ENT SHO and treated for suspected tonsillitis. Awaiting bloods and throat swab results.

The team are concerned because Dwane is now very breathless. Please can you review Dwane urgently.

On further questioning:

  • The sore throat has been going on for a couple of days. Dwane couldn’t eat or drink at all today so decided to come to hospital. The throat doctor started some medicines about 10 minutes ago. But this breathing problem only started about 5 minutes ago
  • Nothing like this has ever happened before
  • Dwane has no past medical history or regular medications
  • He doesn’t smoke or drink and leads a healthy lifestyle

HR 112, BP 88/64, RR 20, SpO2 91% OA, Temp 37.8C, Alert but agitated



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.


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.


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



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.


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


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.

Arterial Blood Gas for Dwane Blake-Watkins

PaO2 is reduced.

Lactate is elevated.

Chest X-Ray for Dwane Blake-Watkins

Normal chest x-ray.



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


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


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

ECG for Dwane Blake-Watkins

  • Rate ~150bpm
  • P waves precede QRS = sinus rhythm
  • Rhythm is regular
  • All waves/intervals are normal

This ECG shows sinus tachycardia.

Blood results for Dwane Blake-Watkins

Mast cell tryptase is elevated - this fits with the picture of anaphylaxis.

The patient has raised CRP, white blood cells and neutrophils. This can be explained by the background of tonsillitis.



Alert but very agitated

GCS 15/15



Bedside CBG – 4.8 mmol/L


None required.



Dwane’s face is flushed


Abdomen SNT

Calves SNT

No peripheral oedema

Mottling/urticaria to the arms and legs


None required.


If students feel treatment is not working, can consider:

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

Post-ABCDE Actions

Can you confirm a diagnosis?

What will you do now?

  1. Re-assess the patient regularly (Now SpO2 95%, BP 101/73, HR 106, wheeze and stridor are improving)
  2. When patient is stable enough to move – take them to resus for further care
  3. Verify diagnosis with senior in ED
  4. Full history and physical examination
  5. Document in the patients notes

Handover using SBAR technique

  1. “Hello my name is X. I have a patient in resus, Dwane Blake-Watkins, with anaphylaxis who needs a senior review.
  2. The patient is a 29 year old male diagnosed with tonsillitis, who was given IV co-amoxiclav this evening. He developed dyspnoea, stridor, and wheeze about 5 minutes after the start of the infusion.
  3. His BP was 88/64 and he was hypotensive and tachycardic. Given the recent antibiotic administration and airway compromise I stopped the IV infusion and gave 0.5mg IM adrenaline, high-flow oxygen and a fluid challenge. Following two doses of IM adrenaline and continued fluids, his BP is now 101/73 and sats are 95%.
  4. Could you please come and review this patient.”