Emergency Medicine

BREATHLESS PATIENT

General Medical Emergencies 67

6 Ta ke a n A BG only if the patient is deteriorating. ABG markers of a life-
threatening attack are:
(i) Normal 34–45 mmHg (4.6–6 kPa), or high PaCO 2 (imminently
fatal).
(ii) Severe hypoxia with PaO 2 under 60 mmHg (8 kPa).
(iii) Low pH (or high hydrogen ion concentration).
(iv) Also check potassium, which may be low.

7 Call the ICU and/or the anaesthetist if the patient remains severe or has any
life-threatening features.
(i) Commence an i.v. bronchodilator under ECG control
(a) give salbutamol 3–6 g/kg i.v. over 10 min, followed by an
infusion of 5 mg salbutamol in 500 mL of 5% dextrose, i.e.
10 g/mL at 5 g/min (30 mL/h or 0.5 mL/min) initially.
Titrate to response up to 20–40 g/min (120–240 mL/h).
(ii) Give magnesium 2 g (8 mmol) i.v. over 20 min.
(iii) Arrange immediate ICU or high-dependency unit (HDU)
admission.

8 Meanwhile, admit under the medical team the initially severe patient who
stabilizes with a PEF maintained over 50%.

9 Alternatively, in the patient with a mild (PEF over 75% predicted) or a moder-
ate (PEF 50 –75% pred ic ted) i n it ia l at t ack who i mproves w it h pred n isolone a nd
nebulizers to a PEF over 75% for at least 1–2 h off treatment:
(i) Discharge if the GP can provide follow-up within 2 days and the
patient has salbutamol and steroid inhalers (and knows how to
use them), plus prednisolone 50 mg orally once daily reduced
over 5 days.
(ii) Admit for overnight observation if there is any doubt about
discharging the patient.

COMMUNITY-ACQUIRED PNEUMONIA (CAP)

DIAGNOSIS

1 Common organisms include Streptococcus pneumoniae (over 50%), ‘atypical’
organisms such as Legionella spp., Mycoplasma and Chlamydia, Haemo-
philus inf luenzae (especia l ly i n COPD), and viruses including inf luenza and
chickenpox.
(i) Less common are Staphylococcus aureus (may follow the ’flu),
Gram-negatives (alcoholism) and Coxiella (Q fever).
(ii) Consider melioidosis in tropical areas due to Burkholderia
pseudomallei, or in diabetics, alcoholism and chronic renal failure
(CRF).