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ED Approach to the Dyspneic Patient

ED Approach to the Dyspneic Patient. University of Utah Medical Center Division of Emergency Medicine Medical Student Orientation. Dyspnea. Subjective feeling of shortness of breath Difficult Labored Uncomfortable Ventilatory demands exceed respiratory function Alterations in:

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ED Approach to the Dyspneic Patient

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  1. ED Approach to the Dyspneic Patient University of Utah Medical Center Division of Emergency Medicine Medical Student Orientation

  2. Dyspnea • Subjective feeling of shortness of breath • Difficult • Labored • Uncomfortable • Ventilatory demands exceed respiratory function • Alterations in: • Gas exchange • Pulmonary circulation • Respiratory mechanics • O2-carrying capacity of blood • Cardiovascular function

  3. Differential Diagnosis

  4. Cases…

  5. Case 1 • 59 yo female • CC: • left upper chest pain • shortness of breath • HPI • Sudden onset while watching television • Increased pain with inspiration • Non productive cough • No fevers or chills • Tried acetaminophen without relief • PMHx • Hypertension • hypercholesterolemia

  6. Case 1 • Surgical Hx • 2 wks s/p partial colectomy for diverticulitis • Social Hx • No tobacco, EtOH or drug use • Married • Works in the food industries • Family Hx • hypertension

  7. Case 1 • ROS: negative • Vitals: T:37 HR: 62 RR: 20 BP: 120/64 SpO2: 98% room air • Physical Exam: essentially normal • Assessment?? Plan?

  8. Pulmonary Embolism • Occurs a lot more than we think it does! • 1.5 million DVT • 30% symptomatic PE, 30% asymptomatic PE • 50k deaths/year • 2.5% mortality if dx’d • 30% mortality if not dx’d • High index of suspicion

  9. Symptoms of Acute Pulmonary Embolism

  10. Pulmonary Embolism • Risk factors • Post-op • Inactivity • casts • Chronic disease • Hypercoagulable states • Malignancies • Protein C&S deficiency • Lupus anticoagulants • Estrogen therapy • Factor V Leiden

  11. Signs of Acute Pulmonary Embolism

  12. Pulmonary Embolism • ECG findings • S1Q3T3 • 25 % of the time • RV strain • Tachycardia • Most common

  13. When to test?!? • Everyone? • High risk only? • Who is safe to clinically rule out PE?

  14. PERC/Well’s Criteria • Clinical rules to limit testing • Low risk pts have false positive rates and morbidity/mortality with treatment • Directs when to work-up

  15. Pulmonary Embolus • Wells Criteria – What is the pre-test probability? • 3.0 Signs/Symptoms of DVT • 1.5 HR>100 • 1.5 Immobilization >3d or surgery in past 4 wks. • 1.5 Prior DVT or PE • 1.0 Hemoptysis • 1.0 Malignancy • 2.0 PE as likely or more likely than alternative diagnosis High Probability > 6.0 Moderate Probability 2.0 – 6.0 Low Probability < 2.0 Wells et al. Ann Int Med 2001; 135:98-107

  16. PERC Rule • Age <50 • HR <100 • RA SpO2 >94% • No prior PE/DVT • No recent surgery • No estrogen • No DVT findings • No hemoptysis Will have a PTP <2% and therefore will not benefit from an evaluation for PE Kline JA et al. J. Thrombosis Haemostasis 2004; 2:1247-1255

  17. Imaging • CXR • V/Q Scan • CT chest • Angiography

  18. CXR

  19. VQ Scan • Normal excludes PE, otherwise in context of patient

  20. 90% sensitive, 95% specific

  21. Pulmonary Embolism • Treatment • High suspicion prior to imaging = heparin • Proven with imaging = heparin (LMW or UFH) • Thrombolytics in select cases • Perimortem • RV dysfunction on echo • Pulmonary HTN on echo • Pulmonary HTN on R heart cath • New ECG signs of RV strain Konstantinides et al NEJM 2002;347(15):1143-1150

  22. Case 1 Summary • Risk: age, post-op • Pleuritic chest pain • Mild tachypnea but vital signs otherwise normal = don’t be fooled! • High index of suspicion!

  23. Case 2 • 85 yo male • CC: Cough, fever • HPI: • 3 days of progressive cough with green sputum production. • Fevers and chills • Pleuritic R sided chest pain • PMHx: CAD, HTN, hypercholesterolemia

  24. Case 2 • Surg Hx: TURP, Coronary stent x 2, appy • Soc Hx: remote tobacco, occasional EtOH, no drug use. Widowed. Retired fisherman. • FHx: Coronary disease • ROS: no HA, abdominal pain, N/V/D, urinary symptoms

  25. Case 2 • Vitals: T 38.5 HR 95 RR 20 BP 105/62 SpO2 94% room air • Physical: • HEENT: dry mucous membranes • Cor: RRR no murmurs • Lungs: LLL crackles & occ wheeze • Abd: soft NT/ND • Assessment?? Plan?

  26. Pneumonia • #1 infectious mortality • #6 overall • 1% as outpt, 25% when needing admission • #1 cause nosocomial infectious mortality • Up to 50% mortality • 25-50% of all ICU pts get pneumonia

  27. Pathogens • Typical S pneumoniae, H Flu, Staphylococcus • AtypicalLegionella, Mycoplasma, Chlamydia • EtohKlebsiella pneumoniae • DM/DKAS pneumoniae/S aureus • HIVbased on CD4 count • COPDHaemophilus influenzae/Moraxella catarrhalis • Sickle CellS pneumoniae/H influenzae

  28. Diagnosis • History/Physical • CXR • CBC • Blood Cx • Urine Cx

  29. Treatment • Ceftriaxone + Macrolide or Fluroquinolone (moxi/levo) • Typical and Atypical coverage • May  to Cefepime for better G- • Hospital/Nursing Home • Health care associated (includes dialysis pts) • Add Vanco • Admit or outpt therapy?

  30. Age: Males: Age Females: Age -10 Nursing home : +10 Comorbid illnesses Neoplastic disease: +30 Liver disease: +20 CHF: +10 CVA disease: +10 Renal disease: +10 Physical examination AMS: +20 RR >30/minute: +20 SBP <90mmHg: +20 Temp <35, >40C: +15 Pulse >125/minute: +10 Laboratory findings pH <7.35: +30 BUN >30: +20 Sodium <130 mEq/L: +20 Glucose >250: +10 Hct <30%t: +10 PO2 <60 mmHg: +10 Pleural effusion: +10 PNA Severity Score

  31. PSS30d Mortality Prediciton

  32. CURB-65 • Confusion? • BUN > 19 mg/dL (7 mmol/L)? • Respiratory Rate ≥ 30? • Systolic BP < 90 mmHg orDiastolic BP ≤ 60 mmHg? • Age ≥ 65? • For each yes answer pt gets 1 point

  33. CURB-65 Score 30 day mortality • 1 = 2.7%, outpt treatment • 2 = 6.8%, consider inpt vs close outpt tx • 3 = 14%, inpt tx, poss ICU • 4 = 27.8%, inpt, prob ICU • 5 = 27.8%, prob ICU tx • CAVEAT: notice the score does not take into account hypoxia.

  34. Atypical Pneumonia

  35. RLL Pneumonia

  36. RUL Pneumonia

  37. LUL Pneumonia

  38. Case 3 • 24 yo female • CC: Shortness of breath, wheezing • HPI: • 2 days of gradual increased shortness of breath • Worse today without relief with albuterol MDI • Non productive cough • No fevers • Recently got a new kitten

  39. Case 3 • PMHx: asthma • No prior hospitalizations • All/Meds: none/albuterol MDI • Surgical Hx: none • Social Hx: ½ ppd tobacco, no EtOH or drugs. Single. Waitress • FHx: COPD • ROS: negative

  40. Case 3 • Vitals: T 37.8 HR 105 RR 22 BP 140/90 SpO2 91% RA • Exam: +accessory muscle use, decreased air movement and very little wheezing • Assessment?? Plan?

  41. Asthma • chronic, nonprogressive lung disorder characterized by: • Increased airway responsiveness • Airway inflammation • Reversible airway obstruction

  42. Physical Exam • Tachypnea • Tachycardia • Cough • Prolonged expiratory phase • Wheezing • NOT an accurate indicator of the severity of an attack • BEWARE of the silent chest!!! • Wheezing may be ABSENT or only barely audible in patients with severe obstruction

  43. Physical Examination Severe obstruction: • Inability to speak • Use of accessory muscles • Altered mental status • Diaphoresis • The ‘silent chest’

  44. Can we accurately risk stratify asthma patients with our exam alone? No… clinicians & patients are notoriously inaccurate when assessing severity. Checking an objective measure of lung function is considered the standard.

  45. Assessment Tools • Clinical scoring systems • Peak expiratory flow rates • Pulse oximetry • Arterial blood gases • Chest radiography • CBC

  46. Peak Expiratory Flow Rates • Should be measured before and after each treatment • Easiest test to perform in the ED

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