Problem 50 A collapsed, breathless woman
You are working in an emergency department overnight and you receive an urgent call from the ambulance service. A paramedic crew is en route to your hospital with a 50-year-old woman who collapsed at home shortly after taking her first dose of antibiotic. Vital signs are: HR 110 bpm, BP 80 mmHg palpable at the radial pulse, oxygen saturation of 92% on room air improving to 98% on high-glow oxygen, Glasgow Coma Scale score (GCS) 14 with some confusion. Facial swelling and wheeze is noted. Nebulized salbutamol and intravenous fluid are being given. Estimated time to arrival is approximately 10 minutes.
The patient arrives on an ambulance stretcher and is wheeled straight into the resuscitation bay.
You note the following on a rapid focused examination of the patient:
Airway: mild stridor and hoarse, soft voice. There is swelling of the face and tongue. There are no airway adjuncts being used.
Breathing: respiratory rate 32 with use of accessory muscles. She can speak in short phrases. There is no tracheal tug. Air entry is moderate, with widespread expiratory wheeze. She continues to saturate between 96 and 98% on 15 L oxygen via a Hudson mask.
Circulation: pulse is thready, tachycardic and regular. She has poor capillary refill of >5 seconds and is cold, sweaty and pale. Her HR is 130 bpm (post salbutamol) and BP is 80/40 mmHg. She has one 18G IV cannula in situ and has received approximately 750 mL of normal saline thus far.
