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==Management==
==Management==
{{Family tree/start}}
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{{familytree | | | A01 | |A01=<div style="float: left; text-align: left; height: 23em; width: 40em; padding:1em;">'''Characterize the symptoms:'''
{{Family tree |border=2|boxstyle=background: WhiteSmoke;|A1|A1=<div style="float: center; text-align: left; height: 6em; width: 12em; padding: 1em">'''COPD Exacerbation''' <BR> ❑ Cough ↑ <BR> ❑ Dyspnea ↑ <BR> ❑ Sputum ↑ </div>}}
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❑ '''Chest pain''' <br> ❑ '''Cough'''<br> ❑ '''Cyanosis'''<br>❑ '''Diaphoresis'''<br>❑ '''Dyspnea'''<br>❑ '''Fever'''<br>❑ Hypotension<br>❑ '''Tachycardia<br>❑ '''Tachypnea'''</div>}}
{{Family tree |!| | | | | | | | | |}}
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{{Family tree |border=2|boxstyle=background:WhiteSmoke;|)|-|B1|B1=<div style="float: left; text-align: left; height: 37em; width: 41em; padding: 1em">
{{familytree | | | B01 | |B01=<div style="float: left; text-align: left; height: 17em; width: 40em; padding:1em;">'''Patient evaluation:'''
 
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'''Oxygen Supplement''' <BR> ❑ Pulse oximetry (maintain Sa<sub>O<sub>2</sub></sub> ≥88—92%)<ref name="Austin-2010">{{Cite journal  | last1 = Austin | first1 = MA. | last2 = Wills |first2 = KE. | last3 = Blizzard | first3 = L. | last4 = Walters | first4 = EH. | last5 = Wood-Baker | first5 = R. | title = Effect of high flow oxygen on mortality in chronic obstructive pulmonary disease patients in prehospital setting: randomised controlled trial. | journal = BMJ | volume = 341 | issue =  | pages = c5462 | month =  | year = 2010 | doi =  | PMID = 20959284 }}</ref> <BR> ❑ Arterial blood gas (if acute or acute-on-chronic respiratory failure is suspected)<sup>†</sup>
❑ '''Obtain a detailed history:'''<br>♦ Age<br>♦ History of heart disease<br>♦ History of chest infection<br>
 
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❑ '''Examine the patient:'''<br>♦ Head/Neck - Neck veins (flat, no ↑JVP)<br>♦ Chest - No S3/S4, no murmurs<br>♦ Limbs - Hyperdynamic pulses, no edema</div>}}
'''Indications for ICU Admission'''<BR> ❑ Hemodynamic instability <BR> ❑ Changes in mental status (confusion, lethargy, coma) <BR> ❑ Severe dyspnea that responds inadequately to initial emergency therapy <BR> ❑ Worsening hypoxemia (Pa<sub>O<sub>2</sub></sub> <40 mm Hg) and/or respiratory acidosis (pH <7.25)
{{familytree | | | |!| | | |}}
 
{{familytree | | | C01 | | |C01=<div style="float: left; text-align: left; height: 30em; width: 40em; padding:1em;">'''Urgent Labs:'''<br> ❑ ABG<br> ❑Calculate A-a gradient<br> ❑ [[CBC]]<br>❑ [[Electrolytes]] <br> ❑ [[BUN]] <br> ❑ [[Creatinine]]<br>❑ [[CXR]]<br>♦ normal-sized heart<br>♦ Peripheral distribution of infiltrates<br>♦ Air-bronchogram (80%)
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'''Consider additional tests based on each patient's presentation:'''<ref name="pmid12974970">{{cite journal| author=Varon J, Marik PE| title=Clinical review: the management of hypertensive crises. | journal=Crit Care | year= 2003 | volume= 7 | issue= 5 | pages= 374-84 | pmid=12974970 | doi=10.1186/cc2351 | pmc=PMC270718 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12974970  }} </ref> <br>


'''Indications for Hospitalization''' <BR> ❑ Marked increase in intensity of symptoms (eg, sudden development of resting dyspnea) <BR> ❑ Severe underlying COPD (GOLD 3—4 categories) <BR> ❑ Onset of new physical signs (eg, cyanosis, peripheral edema) <BR> ❑ Failure of an exacerbation to respond to initial medical management <BR> ❑ Presence of serious comorbidities (eg, heart failure or newly occurring arrhythmias) <BR> ❑ Frequent exacerbations (≥2 events per year) <BR> ❑ Older age (>65 years) <BR> ❑ Insufficient home support</div>}}
<table>
 
<tr class="v-firstrow"><th>❑ Urine [[electrolytes]], [[creatinine]], protein </th><th>❑ [[CT]]/[[MRI]]</th></tr>
{{Family tree |!| | | | | | | | | |}}
<tr><td>❑ Renal ultrasound + doppler </td><td> ❑ [[TSH]], free T3, free T4 </td></tr>
 
<tr><td>❑ Serum [[cortisol]] </td><td> ❑ Serum [[aldosterone]] </td></tr>
{{Family tree |border=2|boxstyle=background:WhiteSmoke;|)|-|C1|-|C2|C1=<div style="float: left; text-align: left; height: 8.5em; width: 36em; padding: 1em">'''Assessment of Exacerbation''' <BR> ❑ Chest radiograph (exclude alternative diagnoses) <BR> ❑ ECG (check coexisting cardiac problems) <BR> ❑ Whole-blood count (identify polycythemia, anemia, or leukocytosis) <BR> ❑ Electrolytes and glucose (identify electrolyte disturbances or hyperglycemia)</div>|C2=<div style="float: left; text-align: left; height: 8.5em; width: 40.5em; padding: 1em">'''Severity of Exacerbation''' <BR> ❑ Mild (require change of inhaled treatment by the patient) <BR> ❑ Moderate (require medical intervention including a short course of ABx or oral steroids) <BR> ❑ Severe (require hospitalization)</div>}}
<tr><td>❑ Serum [[renin]] </td><td> ❑ 24-hr urinary [[catecholamine]] & [[metanephrine]] </td></tr>
 
<tr><td>❑ Serum [[parathyroid hormone]] </td><td> ❑ Urine and serum [[toxicology]] screen </td></tr>
{{Family tree/end}}
<tr><td>❑ Urine [[pregnancy]] test </td><td>❑ [[ANA]]/[[ESR]]/[[CRP]]/anti-dsDNA/anti-smith/rheumatoid factor/p-ANCA/c-ANCA</td></tr>
 
</table>
 
</div>}}}}
 
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{{familytree | | | D01 | | | |D01=}}
 
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{{familytree | | | E01 | | | |E01=}}
<sup>†</sup><small>''Pa<sub>O<sub>2</sub></sub> <60 mm Hg with or without Pa<sub>CO<sub>2</sub></sub> >50 mm Hg in ambient air''</small>
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{{familytree | | | F01 | | |F01=}}
{{familytree | |,|-|^|-|.| | | | | |}}
{{familytree | G01 | | G02 | | |G01=|G02=}}
{{familytree | |!| | | |!| | | | |}}
{{familytree | H01 | | H02 | | | |H01=|H02=}}
{{familytree | | | | | |!| | | | | |}}
{{familytree | | | | | I01 | |I01=}}
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Revision as of 18:26, 20 January 2014

Management

}}
 
 
Characterize the symptoms:
❑ Chest pain
❑ Cough
❑ Cyanosis
❑ Diaphoresis
❑ Dyspnea
❑ Fever
❑ Hypotension
❑ Tachycardia
❑ Tachypnea
 
 
 
 
 
 
 
 
 
 
Patient evaluation:

❑ Obtain a detailed history:
♦ Age
♦ History of heart disease
♦ History of chest infection

❑ Examine the patient:
♦ Head/Neck - Neck veins (flat, no ↑JVP)
♦ Chest - No S3/S4, no murmurs
♦ Limbs - Hyperdynamic pulses, no edema
 
 
 
 
 
 
 
 
 
 
 
Urgent Labs:
❑ ABG
❑Calculate A-a gradient
❑ CBC
❑ Electrolytes
❑ BUN
❑ Creatinine
❑ CXR
♦ normal-sized heart
♦ Peripheral distribution of infiltrates
♦ Air-bronchogram (80%)

Consider additional tests based on each patient's presentation:[1]

❑ Urine electrolytes, creatinine, protein ❑ CT/MRI
❑ Renal ultrasound + doppler ❑ TSH, free T3, free T4
❑ Serum cortisol ❑ Serum aldosterone
❑ Serum renin ❑ 24-hr urinary catecholamine & metanephrine
❑ Serum parathyroid hormone ❑ Urine and serum toxicology screen
❑ Urine pregnancy test ❑ ANA/ESR/CRP/anti-dsDNA/anti-smith/rheumatoid factor/p-ANCA/c-ANCA
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


References

  1. ↑ Varon J, Marik PE (2003). "Clinical review: the management of hypertensive crises". Crit Care. 7 (5): 374–84. doi:10.1186/cc2351. PMC 270718. PMID 12974970.
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