Breathless Patient
64 General Medical Emergencies
- commence heparinization with LMW heparin such as
enoxaparin 1 mg/kg s.c. or unfractionated UF heparin 5000
units i.v. as a bolus, followed by an infusion.
(vi) Admit all patients who required active treatment to a monitored
CCU bed.
6 Bradycardia
This may be sinus, junctional (nodal) or due to atrioventricular block.
(i) Give a bolus of atropine 0.5–0.6 mg i.v.
(ii) Repeat the atropine for sinus or junctional bradycardia if it
persists, to a maximum of 3 mg i.v. total.
(iii) Consider the insertion of a temporary transvenous pacemaker
wire by an expert, if the bradycardia persists with symptomatic
second- or third-degree (complete) AV block, or the patient is
unstable, or
(a) use an external (transcutaneous) pacemaker until X-ray
guidance and expert help are available
(b) small doses of a sedative such as midazolam 0.05 mg/kg and
or morphine 0.05 mg/kg are needed as external pacing is
uncomfortable.
(iv) Avoid excessive atropine or using an isoprenaline infusion
immediately following an acute myocardial infarction, as these
may provoke VF.
BREATHLESS PATIENT
DIFFERENTIAL DIAGNOSIS
Consider the following, some of which were covered in the preceding section on
chest pain:
● Acute asthma
● Community-acquired pneumonia (CAP)
● Chronic obstructive pulmonary disease (COPD)
● Pneumothorax
● Pulmonary embolus (see p. 51)
● Pulmonary oedema
● Acute upper airway obstruction – see page 13
● Metabolic causes, such as acidosis in diabetic ketosis or salicylate poisoning
● Respiratory muscle weakness from myasthenia gravis or Guillain–Barré
syndrome