By Alice Huskinson FY1 in Respiratory Medicine

Know how to recognise anaphylaxis Be able to assess acute patient and initiate basic management Understand the purpose of DNAR forms Know how to discuss DNAR with relatives and patient themselves Consider how these could be potential OSCE stations.

You are the FY1 on call for Respiratory. You get a bleep......

Nurse explains that Bob, a 68 year old man with a CAP, has just become very short of breath, he is now MEWsing at 7.
What are you going to do?

Location of patient Basic observations Let the nurse know you are on your way now and tell them what action to take:
Put the patient on oxygen Repeat observations You will be along straight away

Let your senior know

STOP CAUSE
- is airway patent? No stridor
1 in 1000 IM

B RR - 35 O2 sats 70% on RA. Adrenalin 0.5mls of

Examine chest bilateral wheeze, reduced AE.

C- BP: 80/50, HR 130 regular. CRT 5 seconds. Hydrocortisone 200mg IV

HS 1 + 2 +0, JVP not raised.

D-

2 x wide bore cannula fluids challenge Chlorphenamine 10mg IV GCS 13/15. BM: 4.5

E He has a rash, temperature 37.0

Senior help, may require transfer to ICU CXR ECG ABG Bloods, specifically mast cell tryptase Catheterise If patient has wheeze, treat as for asthma:
Salbutamol nebs 5mg back to back Ipratropium nebs 500micrograms QDS

Document reaction, inform nursing staff.

Type 1 hypersensitivity Ig E mediated reaction. Commonly precipitated by:

Medications Foods, especially nuts Insect bites.

Usually occurs within minutes Symptoms:

Oedema Hypotension and tachycardia Rash SOB

Scenario 2:

Ruth is an 86 year old lady with dementia who currently has a hospital acquired pneumonia. She lacks capacity to make a decision about resuscitation. Your consultant has decided that in her best interests a DNAR should be put in place. You have been asked to discuss this decision with her husband, Malcolm.

Appropriate environment in a side room, bleep free. Elicit their understanding of her current condition. If she should deteriorate seniors feel that it is not in her best interests to commence CPR
It would be very unlikely to be successful CPR is traumatic

Ask if she has ever expressed any thoughts regarding this

Ensure that husband understands exactly what CPR is. DNAR only includes CPR and does not mean any other treatments will be withheld. Elicit any concerns or questions ICE!!!
Husband may be angry that this decision has been made He may be concerned that no decision was made whilst she had capacity

+ if you have time in OSCE ask relative how they are......

Should DNAR forms be discussed with patient if they have capacity? Who can sign DNAR forms?

Where should they be kept?

Who should be told about DNAR forms? What do you do if family disagree with DNAR?

Acute anaphylaxis medications

Adrenaline 0.5mls 1 in 1000 IM Chlorphenamine 10mg IV Hydrocortisone 200mg IV

DNAR

Possible counselling OSCE station. Always elicit concerns of relatives DNAR only includes CPR