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The Deteriorating Patient Case Study Solution

The Deteriorating Patient Case Study Solution

Assessment Task 1

Assessment name: The Deteriorating Patient: Case Studies

Learning outcomes measured:
  1. Consolidate knowledge of key NMBA Registered Nurse Standards for Practice, National Safety and Quality Health Service Standards, and National Health Priorities to enable effective decision making, planning and action in a range of complex clinical situations across the lifespan.
  2. Apply knowledge of anatomy, physiology and pathophysiology to support evidence-based decisions for planning and action.
  3. Demonstrate structured decision making and clinical reasoning to review a range of health situations, synthesise evidence and data, determine priorities, and formulate plans and interventions in line with timeframes and agreed goals. Length: 1500 words +/- 10%
Estimated time to complete task:
  • Approximately 30 hours
  • Weighting: 50%
  • Individual/Group: Individual
  • Authentic Assessment: Yes  No
  • Formative/Summative: Summative
  • How will I be assessed: As a percentage using a rubric
Presentation Requirements:

This assessment task must:

Be a written academic essay containing an introduction, body and conclusion, addressing the task. Use QUT APA referencing for citing academic literature. Assignment cover sheet must be included as the first page of your document Be submitted in electronic format via Turnitin. A minimum 15 references be cited from valid, contemporary journal articles or books no older than 10 years. The use of websites as references is NOT permitted

Task description: For this essay you are asked to pick ONE case scenario related to a type of shock:

  • Option 1: Anaphylaxis
  • Option 2: Hypovolaemia
  • Option 3: Cardiogenic

What you need to do: The 1500 word essay should cover the following points:

  1. Review your chosen case scenario with the lecture and tutorial material associated with the deteriorating patient.
  2. Review your knowledge and understanding related to:
  3. The physiology and pathophysiology of the different types of shock for your selected scenario; b. The physical assessment of those body systems involved; c. The ISBAR framework for effective communication to the medical and/or nursing team

Part 1: You are required to consider the associated signs and symptoms of your chosen condition and discuss the findings as they relate to each part of the ABCDE pneumonic. You need to be able to critically explain the link with the associated signs and symptoms, the pathophysiology/physiology and what the physical assessment identifies. (Approximately 1000 words)

Part 2: Having completed your physical examination of your chosen condition you are required to construct a structured written handover to the doctor using ISBAR. (Approximately 500 words)

Resources needed to complete task:

Case study outlines and clinical documents available on your Blackboard site. Access to Understanding Pathophysiology 2nd edition by Craft et al., (2016). Access to Health Assessment & Physical Examination 5th edition by Estes et al., (2016) QUT Cite|Write APA guide. Turnitin Tip Sheets. Assignment Case Studies

Anaphylaxis  Jim Palmer is a 53 year old farmer who was admitted this morning with severe cellulitis to his left lower leg; he has already received one dose of Flucloxacillin 1gram IV as a slow bolus in the Emergency Department. You give him is second dose of Flucloxacillin. Ten minutes later Jim’s call bell rings and upon arrival you find him breathless and complaining of a tight feeling in the throat and feeling lightheaded and dizzy. As you begin to assess Jim, you also notice his level of consciousness is reducing.

Hypovolaemia Maureen Hardy is a 77 year old women who has been sent in by her GP for review who has had two episodes of haematemesis at home. Four hours after arriving on your ward she vomits blood and has blood around her mouth, you also note that she appears pale, sweaty and drowsy. Maureen is responding only to verbal stimuli.

Cardiogenic Frank James a 72 year old man has been admitted to your ward with an acute exacerbation of his chronic heart failure. He is sat in a semi-high fowler’s position, mildly diaphoretic, slightly short of breath and complaining of nausea. The next morning Mr. James continues to complain of shortness of breath and restless with a chest pain score of 2. The MO orders an urgent chest x-ray and it is noted in his medical notes that his heart failure is worsening and he has developed pulmonary oedema. On examination he is confused, sweating and pale.

Assignment Hints The assignment is asking what you findings would be if you were to undertake a physical examination of your chosen case study and report back using ABCD. Remember the patient profile might not cover all aspects of ABCD. For example if your patient was short of breath you would explain how, what and why they were short of breath.

The What: what did your physical examination find? The How: how did it manifest itself? The Why: why did this occur?

To put this into perspective. The patient presents with pneumonia. Your physical examination for breathing reveals asymmetrical chest movements when the patient is asked to take a deep breath and they are using accessory muscle breathing, you note tachypnea, some central cyanosis and when you percuss you hear a dull sound over the affected lung. Auscultation reveals course crackles on expiration that clear with coughing and reduced air entry on the effected side.  The sputum that is produced is green and purulent.  Now critically explain how and why this is occurring. For this you will need to review your physiology and pathophysiology of breathing and pneumonia. So the books you will need to review to get you started are:

Reflecting on what you found write an ISBAR of the relevant and pertinent information you would convey to the doctor.

Anaphylaxis Case Study

Jim Palmer is a 53 year old farmer who was admitted this morning with severe cellulitis to his left lower leg; he has already received one dose of Flucloxacillin 1gram IV as a slow bolus in the Emergency Department. You give him his second dose of Flucloxacillin. Ten minutes later Jim’s call bell rings and upon arrival you find him flushed, breathless and complaining of a tight feeling in the throat and feeling lightheaded and dizzy. Jim has bilateral chest movements and the depth of his breathing is shallow, you can hear an audible wheeze and has some central cyanosis. As you begin to assess Jim, you also notice his level of consciousness is reducing, he is becoming drowsy and responding to voice only.

His observations are:

– Resps 26bpm – BP 99mmHg systolic on palpation – HR 130bpm regular – Temp 37.4°C – SaO2 91% on RA

Jim’s peripheries are cool and clammy. His capillary refill time is >4secs. There is wide spread urticarial rash (picture below) and swelling of his lips, fingers and toes. His blood glucose is 5.3mmols/ltr

Hypovolaemia Case Study

Maureen Hardy is a 77 year old women who has been sent in by her GP for review who has had two episodes of haematemesis at home. Four hours after arriving on your ward she vomits blood and has blood around her mouth, you also note that she appears pale, sweaty and drowsy. Maureen is responding only to verbal stimuli on the AVPU scale. She has been taking the following medication:

Diclofenac Acid 50mgs PO (with food) BD for arthritic knees, Warfarin 2mgs PO mane for atrial fibrillation (INR 2.7)

Her observations are:

– BP 80mmHg systolic – HR120bpm and irregular – Resps 28bpm – SaO2 unreadable  – Capillary refill time >4secs – Temp 36.5°C (core)

You also note that her pupils are dilated 3-4mms but are equal and reactive to light. She has equal bilateral chest movement and the depth of breathing is normal. She has a slightly distended abdomen.

The lab results have also arrived which show:

– Haemoglobin 9g/dL (12-15g/dL) – Platelets 150000 (100,000-450,000K/uL) – Haematocrit 27% (36-44%)

Her Chest X-ray is normal

And her ECG reveal sinus tachycardia:

Cardiogenic Case Study

Frank James a 72 year old man has been admitted to your ward with an acute exacerbation of his chronic heart failure. He is positioned in a semi-high fowler’s position, is mildly diaphoretic, slightly short of breath and complaining of nausea. Mr. James has a history of stable angina for an undetermined period. However, he has revealed that for the past 3 weeks, he has been experiencing pain radiating to his back every hour, which is relieved with sublingual nitroglycerin (GTN). There is a family history of cardiovascular disease with an older brother dying from a myocardial infarction (MI) and a sister who has had 3 MI’s. Mr. James has a 30 year history of cigarette smoking and continues to smoke 1 pack/day. He has been taking the following medication:

Aspirin 7mgs PO mane, Atenolol 50mgs PO mane, Isosorbide mononitrate 30mgs PO nocte, Lisinopril 10mgs PO mane

The next morning Frank continues to complain of shortness of breath and restlessness with a chest pain score of 8/10 that is radiating to his left arm. The MO orders an urgent chest x-ray and it is noted in his medical notes that his heart failure is worsening and he has developed pulmonary oedema. On examination he is confused, sweating, pale and centrally cyanosed.

His observations on admission and currently are as follows:

On Admission Currently

Am Pm  BP 156/98mmHg  HR 124  Resps 30bpm  Temp 37°C  140/100mmHg  HR 130bpm  Resps 28bpm  SaO2 92% on 10ltrs FiO2  BP 96/50mmHg  HR 128bpm  Resps 36bpm  U/O 20mls/hr for the past 2 hours

His 12 lead electrocardiogram (ECG) reveals Q waves, ST depression and T wave inversion which may signify ischemia.

His chest x-ray reveals diffuse infiltrates that resemble “bat wings” consistent with pulmonary oedema.

Q waves T wave Inversion ST Depression

“Bat wings”

NSB236 Assessment Task 1 Rubric Name:

Learning outcomes assessed:  1, 2 and 3

Weighting:  50 %

Criteria 7 6 5 4 3 2 – 1

Critical Thinking & Knowledge   Weighting 50%

Consolidate knowledge of key NMBA Registered Nurse Standards for Practice, National Safety and Quality Health Service Standards, and National Health Priorities to enable effective decision making, planning and action in a range of complex clinical situations across the lifespan.

  • Assignment content: critical explanation reflects a comprehensive interpretation and critical explanation of the assessment data;
  • Assignment content: critical explanation reflects good interpretation and critical explanation of the assessment data;
  • Assignment content: critical explanation reflects sound interpretation and some critical explanation of the assessment data;
  • Assignment content: critical explanation reflects basic interpretation and some or no critical explanation of the assessment data – content not overly discerning;
  • Assignment content: limited critical explanation reflects poor interpretation and no critical explanation of the assessment data – content not discerning;
  • Assignment content: no critical explanation reflects poor interpretation and no critical explanation of the assessment data – content not discerning;
  • Comprehensive understanding of the central issues of the question – all key physical assessment issues addressed;
  • Good understanding of the central issues of the question – almost all key physical assessment issues addressed;
  • Sound understanding of the central issues of the question – most key physical assessment issues addressed;
  • Fair understanding of the central issues of the question – some key physical assessment issues addressed;
  • Poor understanding of the central issues of the question – not all key physical assessment issues addressed;
  • No understanding of the central issues of the question – no key physical assessment issues addressed;
  • Demonstrated a comprehensive depth of reasoning and logical and analytical thinking
  • Mostly demonstrated a depth of reasoning and logical and analytical thinking
  • Soundly demonstrated a depth of reasoning and logical and analytical thinking
  • Adequately demonstrated depth of reasoning and logical and analytical thinking
  • You have not adequately demonstrated depth of reasoning and logical and analytical thinking
  • You have not demonstrated depth of reasoning and logical and analytical thinking
  • Apply knowledge of anatomy, physiology and pathophysiology to support evidencebased decisions for planning and action.

Weighting 15%

  • Comprehensive application of pathophysiological and physiological concepts  which demonstrated an understanding of links between the patient condition and assessments performed
  • Good application of pathophysiological and physiological concepts  which demonstrated an understanding of links between the patient condition and assessments performed
  • Sound application of pathophysiological and physiological concepts  which demonstrated an understanding of links between the patient condition and assessments performed
  • Fair application of pathophysiological and physiological concepts  which demonstrated a fair understanding of links between the patient condition and assessments performed
  • Poor application of pathophysiological and physiological concepts  which demonstrated little understanding of links between the patient condition and assessments performed
  • No application of pathophysiological and physiological concepts  which demonstrated no understanding of links between the patient condition and assessments performed
  • Apply knowledge and skills to communicate and collaborate effectively.  Weighting: 25 %
  • You succinctly and accurately described essential information in each element of the ISBAR framework.
  • You clearly and accurately described mostly essential information in each element of the ISBAR framework.
  • You soundly and accurately described essential information in each element of the ISBAR framework.
  • You adequately and sometimes accurately described essential information in each element of the ISBAR framework.
  • You have not adequately and accurately described essential information in each element of the ISBAR framework.
  • ISBAR framework not used.
  • Your handover flowed logically and contained only essential information that related to the health problems identified from the comprehensive physical assessment of the case study.
  • Your handover was logical in most parts and contained mostly essential information that related to the health problems identified from the comprehensive physical assessment of the case study.
  • Your handover was sound and somewhat logical with some essential information that related to the health problems identified from the comprehensive physical assessment of the case study.
  • Your handover was adequate and somewhat logical that related to the health problems identified from the comprehensive physical assessment of the case study.
  • Your handover was inadequate and not logical. You have missed crucial sections of essential information that related to the health problems identified from the comprehensive physical assessment of the case study.
  • Your handover was wholly inappropriate inadequate and not logical. You have missed large sections of essential information that related to the health problems identified from the comprehensive physical assessment of the case study.
  • Used correct terminology and professional language consistently with the case study.
  • Used correct terminology and professional language for most of the handover the case study.
  • Used correct terminology and professional language for some of the handover the case study.
  • Used correct terminology and professional language for part of the handover the case study.
  • You have not used correct terminology and professional language for the majority of the handover the case study.
  • Correct terminology and professional language used infrequently the case study.
  • Correctly cited all sources both within the text and reference list with no errors;
  • Correctly cited all sources both within the text and reference list with few errors;
  • Correctly cited most sources both within the text and reference list with s0me errors;
  • Correctly cited some sources both within the text and reference list with a number of errors;
  • Poor citation of sources both within the text and reference list;
  • Consistently and correctly used QUT APA referencing style;
  • Correctly used QUT APA referencing style;
  • Used QUT APA referencing style with minimal errors;
  • Used QUT APA referencing style with occasional errors;
  • Referencing style inconsistently applied and inaccurate;
  • Expressed ideas clearly, concisely and fluently with correct spelling and grammar;
  • Expressed ideas reasonably clearly, concisely and fluently with minimal spelling and grammatical errors;
  • Expressed most ideas clearly with minimal spelling and grammatical errors;
  • Expressed most ideas clearly with occasional spelling and grammatical error;
  • Poor communication of ideas with frequent spelling and grammatical error;
  • Did not use direct quotes;
  • Rarely used direct quotes;
  • Sometimes used direct quotes;
  • Overuse of direct quotes;
  • Kept to word limit. Kept to word limit. Word limit under/over the 10% allowance.
  • Struggled with word limit.
  • Not within required word limit.

The Deteriorating Patient:

Introduction

Anaphylaxis is one of the most common conditions nurses come across in the course of their work. Although it has not had a universally accepted definition, a number of researchers and scholars have made numerous attempts to describe the condition. According to Johanson as cited by Allen (2016), anaphylaxis is a severe, life-threatening, generalized or systematic hypersensitivity reaction (Estelle & Simons, 2009). There are various types of anaphylaxis depending upon the cause of the condition. According to Mali & Jambure (2012), some of the most common types include drug-induced anaphylaxis, anesthesia-related anaphylaxis, latex-induced anaphylaxis among others. In the discussion that follows, we analyze a case of drug-induced anaphylaxis through the assessment of Jim Palmer, a 53 year old patient as presented in the anaphylaxis case study.

Body

Part 1

The structured ABCDE approach has proved to be significantly successful and appropriate in not only the training of the necessary skills in life support courses, but is also an imperative kit in the understanding of a patient’s condition (Thim et al. 2012). The ABCDE approach assesses the patient with regard to the nature of the airways, the breathing patterns, circulation of air, disabilities and disorders resulting from the condition and the full exposure of the patient. According to Thim et al. (2012), this should be the initial assessment approach for patients demonstrating anaphylaxis conditions.

Having received approval in most emergency cases, the ABCDE approach to achieve five main aims and objectives. It seeks to provide a life-saving treatment, break down complex medical conditions, serves as an assessment and treatment algorithm, establishes common situational awareness among all the different treatment providers and buys time to establish the final diagnosis and treatment for the patient (Thim et al., 2012). Thim et al. (2010) argues that the approach can effectively be applied in the streets without any equipment, or in advanced forms such as in the emergency departments, general wards in hospitals or even in the intensive care units. In the discussion that follows, we assess Mr. Palmer through the application of the ABCDE assessment tool as described above.

Airways

The first element of the ABCDE seeks to assess whether or not the patient’s airway is patent. With a complete obstruction of the patient’s airways, there is no respiration despite any efforts applied by the medics. As a result, the patency of the patient is the first assessment in the ABCDE assessment approach. A critical assessment of the patient demonstrates a number of signs for partial obstruction of the airways. As described in the case, the patient is breathless upon view by the nurse. The patient also has bilateral chest movements and demonstrates a shallow depth of breathing. The patient demonstrates audible wheeze on breathing and has some central cyanosis.

The signs and symptoms observed from the patient are similar to the signs and symptoms of anaphylaxis resulting from penicillin (Simons et al., 2011). According to Thim et al. (2012), the main signs that should lead to the medics ruling for airway obstruction include changed voice, noisy breathing and increased breathing effort. Bhattacharya (2010) also notes that one of the notable signs of anaphylaxis from penicillin drugs results in an immediate decline in blood pressure and the volume of blood. These signs and symptoms as observed in the patient demonstrate a case of airway obstruction.

According to Bhattacharya (2010), anaphylaxis occurs when mast cells are exposed to the antigen-specific IgE and a systematic exposure to the antigens occur, thereby cross-linking the IgE (Bonadonna et al., 2009). The result is a significantly high simultaneous degranulation of a large proportion of the mast cells. Since the mast cells comprises of histamine as well as other vaso-active mediators, the sudden release of these mediators results in the conditions as observed in the case of Jim Palmer. According to Bryson, Frost, Rosenblatt (2007), the figure below shows the chain of reactions that result in the signs and symptoms as observed in anaphylaxis.

The Deteriorating Patient Case Study Solution

Figure 1: Hypersensitivity reaction of penicilin, mechanisms of action Source: Bryson, Frost, Rosenblatt (2007)

Breathing

The second consideration is any form of life threatening breathing conditions. The objective as explained by Thim et al. (2012) is to assess whether breathing is sufficient to sustain life of the patient. The main aspects of focus in breathing assessment include the rate of respiration, movement of the thoracic walls, occurrence of cyanosis, distended neck veins and the lateralization of the neck veins. A closer look at the conditions of Mr. Palmer indicates insufficient breathing conditions.

According to the case study, the respiration rate of the patient is as high as 26bpm with a capillary refill rate of above 4 seconds. In addition to these, the patient demonstrates bilateral chest movements and some central cyanosis. Moreover, the oxygen saturation rate of the patient was observed to be 91%, a rate that is below that of a normal individual. According to the patient, he experiences a tight feeling of the throat, which demonstrates the availability of distended neck veins (Thim et al., 2012). These signs and symptoms are sufficient to conclude that Mr. Palmer experiences insufficient breathing.

Circulation

The objective is to assess whether the patient’s blood circulation is sufficient. The patients capillary refill rate and pulse rate are the main indications of problems in blood circulation (Thim et al., 2012). According to the case study, the patient’s capillary refill rate is far below that of the normal person which is usually less than 2 seconds. In addition, the patient’s blood pressure was observed to be 90mmHg, which is less than the blood pressure of a normal adult which is 120/80 mmHg which suggests arterial vasoconstriction. The other primary indication of problems in blood circulation is the color of the patient’s skin. As observed in the image shown below, the patient is pink in the back. The patient also expresses reduced consciousness which is one of the signs of reduced perfusion (Thim et al., 2012). These signs and symptoms are enough evidence that the patient under consideration suffers from blood circulation problems.

The Deteriorating Patient Case Study Solution

Disabilities

This assesses the level of consciousness of the patient. According to Thim et al. (2012), the patient should be graded as alert (A), voice responsive (V), pain responsive (P) or unresponsive. According to the case study, Mr. Palmer’s level of consciousness decreases with time and is only responsive to voice. As such, the patient’s appropriate grading is V.

Exposure

Finally, the ABCDE seeks to search for any clues towards explaining the condition. The primary observable clue of the condition is the condition of the skin. According to the case study, the patient has rushes and appears flushed. The patient is also lightheaded and dizzy.

Conclusion

The above analysis shows many signs and indications that the patient suffers from allergy. These signs and symptoms, together with the above explained signs indicate a possible anaphylaxis resulting from penicillin drugs (Thim et al., 2012). With the consideration that the only drug that the patient has been administered to is Flucloxacillin, which is one of the penicillin drugs, it can thus be concluded that the patient suffers from anaphylaxis from Flucloxacillin overdose.

Part 2: ISBAR Clinical Handover

IdentificationTherapist providing handover<Author’s name>
Therapist accepting handover<receiver’s name>
Date<Date>
Patient nameJim PalmerAge 53
MRNLocation
GenderMale
 
SituationDiagnosis/ Reason for admissionThe patient was admitted with a severe cellulitis to his left leg.
Presenting concernHe was administered with a Flucloxacillin overdose and is presenting anaphylaxis condition.
BackgroundBackground information·         The 53 years old patient was admitted to the hospital today following a severe cellulitis on the left leg.

·         The patient was initially administered with one dose of Flucloxacillin before he was given another dosage of the same drug.

·         He is a farmer and works from his farm.

·         The condition of anaphylaxis emanated from the treatment given in the morning.

Previous OT input
AssessmentKey Issues / Goals·         An ABCDE assessment of the patient demonstrates obstruction of the airways, difficulties in breathing, problems in blood circulation.

·         The patient is flushed, and has his consciousness reducing with time.

·         His is voice responsive only.

·         These signs and symptoms points to anaphylaxis from a Flucloxacillin overdose.

RecommendationActions requiredTime Frame / Priority
For receiving handover therapist to complete
Actions Taken ·         Avoid any further administration of Flucloxacillin.

·         Head tilt and chin lift to open the airways (Koster et al., 2010).

·         Provide adrenaline 0.01 mg/kg into the lateral thigh to a maximum 0.5 mg. This may be repeated 5 – 15 minutes (Brown, 2009).

·         Provide high flow oxygen to promote continued respiration (Lieberman et al., 2010).

Further Actions required ·         Ensure continued provision of oxygen until the patient can breathe on his own.

·         Continue administration of adrenaline as prescribed earlier.

·         Desensitization may be performed in order to convert the patient to a state in which he can tolerate the penicillin drugs as may be required during the treatment of cellulitis (Karabus & Motala, 2009).

How did the handover occurFace to FaceEmailWritten only
Saved on OT clinical handover driveCompletedDate & Time handover occurred
References;
  • Allen, D.  (2016). Anaphylaxis: a study of the condition and treatment. Links to Health and Social Care, 1(1), pp. 44 – 58.
  • Bhattacharya, S. (2010). The facts about penicillin allergy: a review. Journal of Advanced Pharmaceutical Technology & Research, 1(1), 11-17.
  • Bonadonna, P., Perbellini, O., Passalacqua, G., Caruso, B., Colarossi, S., Dal Fior, D., et al. (2009). Clonal mast cell disorders in patients with systemic reactions to Hymenoptera stings and increased serum tryptase levels. J Allergy Clin Immunol. 123(1), 680–686.
  • Brown, F. (2009). Current management of anaphylaxis. Emergencias. 21(1), 213–223.
  • Bryson, E., Frost, E. & Rosenblatt, M. (2007). Management of the patient reporting an allergy to penicillin. Middle East Journal of Anesthesiology, 19(3), 496 – 500.
  • Craft, J., Gordon, C., Huether, S., McCance, K. & Brashers, V. (2016). Understanding pathophysiology – ANZ adaptation (2nd Ed.). Elsevier: Elsevier Health Sciences.
  • Estelle, F. & Simons, R. (2009). Anaphylaxis: Recent advances in assessment and treatment. J Allergy Clin Immunol. 124(1), 625–636.
  • Estes, M. & Schaefer, K. (2016). Health assessment and physical examination (2nd Ed). New York: Delmar/Thomson Learning.
  • Karabus, S. & Motala, C. (2009). Penicillin Allergy in Children. Current Allergy & Clinical Immunology, 22(2), 64-66.
  • Koster, R., Baubin, M., Bossaert, L., Caballero, A., Cassan, P., Castren, M., Granja, C., Handley, A., Monsieurs, K., Perkins, G., Raffay, V. & Sandroni, C. (2010). European Resuscitation Council Guidelines for Resuscitation 2010 Section 2. Adult basic life support and use of automated external defibrillators. Resuscitation, 81(10), 1277 – 1292.
  • Lieberman, P., Nicklas, A., Oppenheimer, J., Kemp, F., Lang, M., Bernstein, I., Bernstein, A., Burks, W., Feldweg, M., Fink, N., Greenberger, A., Golden, B., James, M., Kemp, F., Ledford, K., Lieberman, P., Sheffer, L., Bernstein, I., Blessing-Moore, J., Cox, L., Khan, A., Lang, D., Nicklas, A., Oppenheimer, J., Portnoy, M., Randolph, C., Schuller, E., Spector, L., Tilles, S., Wallace, J. (2010). The diagnosis and management of anaphylaxis practice parameter: 2010 update. Allergy Clin Immunol, 126(3), 477-480.
  • Mali, S. & Jambure, R. (2012). Anaphyllaxis management: Current concepts. Anesthesia Essays and Researches, 6(2), 115-123.
  • Mueller, R. (2007). Cardiovascular disease and anaphylaxis. Curr Opin Allergy Clin Immunol., 7(1), 337–341.
  • Simons, R., Estelle, F., Ardusso, F., Beatrice, M., El-Gamal, M., Ledford, K., et al. (2011). World Allergy Organization Guidelines for the Assessment and Management of Anaphylaxis. WAO J. 4(1), 13–37.
  • Thim, T., Krarup, H., Grove, L., Lofgren, B. (2010). ABCDE – a systematic approach to critically ill patients. Ugeskr Laeger, 172(47), 3264–3266.

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