Emergency Medicine

BREATHLESS PATIENT

General Medical Emergencies 71

(b) use moxifloxacin 400 mg daily i.v. with azithromycin, if the

patient has penicillin allergy or significant renal impairment

(c) give meropenem 1 g 8-hourly i.v. plus azithromycin 500 mg

daily i.v. for severe tropical pneumonia where B. pseudomallei

(melioidosis) or Acinetobacter baumannii are prevalent.

Chronic obstructive pulmonary disease

DIAGNOSIS

1 Causes of chronic bronchitis with emphysema (COPD) include smoking,
environmental pollution, occupational exposure such as silica, repeated or
chronic lung infection, and -1 antitrypsin deficiency.

2 Productive cough, dyspnoea, wheeze and reduced exercise tolerance worsen
with exacerbations, until end-stage disease when there is minimal variation.

3 Ask about normal daily exercise capacity and level of dependence.
(i) Enquire about current medication, home oxygen use, previous
hospital admissions and associated cardiac disease.

4 Exacerbation of COPD.
This is usually multi-factorial, so consider the many underlying causes
possible:
(i) Infection; bronchospasm; pneumothorax; pneumonia; right, left
or biventricular heart failure; cardiac arrhythmia including AF;
myocardial infarction.
(ii) Non-compliance with medication including steroid underdosing;
iatrogenic response to excess sedatives, opiates or inadvertent
-blockade; environmental allergens or weather change;
malignancy and a PE.

5 Examine for fever, lip pursing, tachypnoea, tachycardia and wheeze. Also
look for:
(i) Cyanosis, ruddy complexion and signs of right heart failure due
to cor pulmonale with a raised JVP and peripheral oedema.
(ii) Carbon dioxide retention causing headache, drowsiness, tremor
and a bounding pulse.

6 Establish venous access and send blood for FBC, ELFTs, glucose and two sets
of blood cultures if pyrexial. Attach a cardiac monitor and pulse oximeter to
the patient.

7 Take an ABG if patient is clearly unwell, to look for hypoxia PaO 2 <60 mmHg
(8 kPa), hypercarbia PaCO 2 >45 mmHg (6 kPa) and a raised bicarbonate
indicating compensated respiratory acidosis.

8 Perform an ECG and look for large P waves (P pulmonale), right ventricular
hypertrophy or strain (cor pulmonale), and signs of ischaemia with ST and T
wave changes.