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Thursday, 6 October 2016

A 62-year-old man with acute shortness of breath and low oxygen saturation

A 62-year-old man was brought to the emergency room with acute shortness of breath. 

He was hypertensive, on candesartan, and suffered ischemic cerebral infarction 12 months earlier, with residual impairment of his swallowing. 

Since then he was being fed via a gastrostomy tube.

His daughter said that he vomited twice, 4 hours before the onset of breathlessness.

On examination he was tachypneic and hypoxemic. Blood pressure was 150/90, pulse was 110/minute and temperature was 38°C.
Auscultation of the chest revealed bilateral crackles and rhonchi.

Chest x-ray showed bilateral patchy infiltrates.

Which of the following is indicated in the management of this patient's acute illness?

A-    Prophylactic antibiotics
B-    Intravenous hydrocortisone
C-    Supplemental Oxygen
D-   Intravenous furosemide
E-     Inhaled bronchodilator

Check correct answer and explanation below:

Image result for emergency room

Correct answer is C

This patient's presentation strongly suggested acute gastric content aspiration, since his swallowing is impaired, and the event immediately followed bouts of vomiting.

Monitoring Oxygen saturation is essential as assisted ventilation may be required.

There is no evidence that corticosteroids are beneficial, nor antibiotics will change the outcome (except when there is evidence of secondary bacterial infection).

Diuretics are not indicated here. Instead, intravenous fluids should be administered, because of the intravascular fluid loss through disrupted alveolar capillary membrane.

Inhaled has no benefit in relieving symptoms nor improving Oxygen saturation.

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