Silence isn’t always golden

Author: Sandi Angus / Editor: Nick Tilbury / Codes: / Published: 16/06/2022

A 22-year-old female presents via ambulance to the Emergency Department (ED) in the early hours of the morning with acute shortness of breath on the background of a 5-day history of cough, fever and general malaise.

She has no past medical history, no regular medications and no drug allergies. She has had several negative COVID lateral flow tests over the last few days.

The nurse-in-charge moves her to the resuscitation area due to her profound breathlessness.

Her observations and examination findings are as follows:

A Patent, self-maintained.

B – RR 25, SpO2 100% on oxygen-driven nebuliser from crew, 94% on room air 10 minutes post-nebuliser.

You observe features of respiratory distress with accessory muscle use and an inability to speak in full sentences. On auscultation, there is poor air entry throughout, with occasional bilateral, expiratory wheeze.

C BP 124/67, HR 139 with a sinus tachycardia on 12-lead ECG. Normal jugular venous pressure (JVP). No pedal oedema.

D Alert, BM 6.1. No neurological abnormalities.

E Temp 37. Abdomen soft, non-tender. No signs of deep vein thrombosis (DVT) in lower limbs.

She has been treated by the crew with one mixed nebuliser of Salbutamol 5mg and Ipratropium Bromide 500mcg and a further two Salbutamol nebulisers, one of which is still ongoing.

An arterial blood gas (ABG) is taken while the patient is on the latest oxygen-driven nebuliser:

  • pH 7.32 (7.35-7.45)
  • pCO2 5.14 (4.6-6.1kPa)
  • pO2 14.0 (10-13kPa)
  • HCO3 19.6 (22-28mmol/L)
  • BE -5.9 (-2 – +2)
  • Lactate 3.86 (0.5-2.2mmol/L)

You perform a bedside chest X-ray, which is as follows:

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