A 27-Year-Old Man Comes to the Emergency Department with Sudden

question 585

Multiple Choice

A 27-year-old man comes to the emergency department with sudden onset of shortness of breath.  He ran out of his asthma medication 10 days ago.  He has been intubated twice in the past 6 months due to severe asthma exacerbations.  On physical examination, his temperature is 37.2 C (99 F) , blood pressure is 142/64 mm Hg, heart rate is 110/min, and respirations are 28/min.  His oxygen saturation is 84% on room air and improves to 94% on nonrebreather mask.  The patient is alert but appears to be in respiratory distress with some use of accessory muscles of respiration.  His lung examination shows equal, bilateral air entry with diffuse wheezing throughout both lung fields.  His peak expiratory flow rate is 60% of his personal best, based on his prior admissions. While in the emergency department, the patient's respirations become more labored.  He is now markedly diaphoretic and has visible suprasternal retractions.  He appears exhausted and drowsy.  Repeat vital signs are temperature of 37.2C (99 F) , blood pressure of 110/74 mm Hg, pulse of 106/min, and respirations of 10/min.  His oxygen saturation is 95% on nonrebreather mask.  Lung examination shows bilaterally equal but markedly reduced air entry with minimal wheezing on both sides.  The patient is not able to follow instructions to use the peak flow meter.  Which of the following is the most important next step in management?

• A)Admit and give a single dose of 2 g intravenous magnesium sulphate
• B)Admit and give continuous inhaled beta-2 agonists and inhaled ipratropium
• C)Admit and give continuous inhaled beta-2 agonists and intravenous corticosteroids
• D)Perform immediate endotracheal intubation and mechanical ventilation
• E)Start the patient on intravenous theophylline in the emergency department

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