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CLINICAL PROBLEM SOLVING WHEN YOU’RE ON CALL

CLINICAL PROBLEM SOLVING WHEN YOU’RE ON CALL. Speaker: Connie Tomada, MD. CLINICAL PROBLEM SOLVING WHEN YOU’RE ON CALL. How to work-up and manage Shortness of Breath. Shortness of Breath. Phone Call. duration? gradual or sudden? cyanosis? reason for admission?

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CLINICAL PROBLEM SOLVING WHEN YOU’RE ON CALL

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  1. CLINICAL PROBLEM SOLVING WHEN YOU’RE ON CALL • Speaker: Connie Tomada, MD

  2. CLINICAL PROBLEM SOLVING WHEN YOU’RE ON CALL • How to work-up and manage • Shortness of Breath

  3. Shortness of Breath

  4. Phone Call • duration? • gradual or sudden? • cyanosis? • reason for admission? • presence of COPD or heavy smoking? (CO2 retainers) • oxygen order?

  5. Phone Call • Oxygen • 1 L/min O2 on NC adds 3% FiO2 on RA • for CO2 retainers, start with 3-4 L/min, FiO2 29-32% • for asthma/COPD, aerosol treatment • ABG?

  6. Travel Time

  7. Travel Time

  8. Bedside • rapid visual assessment (sick or critically ill?) • ABG, O2, IV access & IV fluids, ECG • crash cart and ECG monitor • code status if considering intubation (call senior resident/ICU attending)

  9. Bedside • ABCs and Vital signs • airway obstruction • RR<12/min: narcotic OD, cushing sign • paradoxical breathing • fever: infection vs. PE • pulsus paradoxus: asthma, COPD, cardiac tamponade

  10. Bedside • Hypoxia (O2sat<92% or PaO2<60 mmHg) • increase oxygen support until O2 sat >92% • careful with CO2 retainer (COPD, heavy smoker), O2sat ~90% • nasal cannula face mask venturi mask non-rebreather dual flow BiPap endotracheal intubation • repeat ABG

  11. Bedside • Hypoxia (O2sat<92% or PaO2<60 mmHg) • increase oxygen support until O2 sat >92% • careful with CO2 retainer (COPD, heavy smoker), O2sat ~90% • nasal cannula face mask venturi mask non-rebreather dual flow BiPap endotracheal intubation • repeat ABG

  12. Bedside • Hypoxia (O2sat<92% or PaO2<60 mmHg) • increase oxygen support until O2 sat >92% • careful with CO2 retainer (COPD, heavy smoker), O2sat ~90% • nasal cannula face mask venturi mask non-rebreather dual flow BiPap endotracheal intubation • repeat ABG

  13. Bedside • Hypoxia (O2sat<92% or PaO2<60 mmHg) • increase oxygen support until O2 sat >92% • careful with CO2 retainer (COPD, heavy smoker), O2sat ~90% • nasal cannula face mask venturi mask non-rebreather dual flow BiPap endotracheal intubation • repeat ABG

  14. Bedside • Hypoxia (O2sat<92% or PaO2<60 mmHg) • increase oxygen support until O2 sat >92% • careful with CO2 retainer (COPD, heavy smoker), O2sat ~90% • nasal cannula face mask venturi mask non-rebreather dual flow BiPap endotracheal intubation • repeat ABG

  15. Bedside • Hypoxia (O2sat<92% or PaO2<60 mmHg) • increase oxygen support until O2 sat >92% • careful with CO2 retainer (COPD, heavy smoker), O2sat ~90% • nasal cannula face mask venturi mask non-rebreather dual flow BiPap endotracheal intubation • repeat ABG

  16. Bedside • Hypoxia (O2sat<92% or PaO2<60 mmHg) • increase oxygen support until O2 sat >92% • careful with CO2 retainer (COPD, heavy smoker), O2sat ~90% • nasal cannula face mask venturi mask non-rebreather dual flow BiPap endotracheal intubation • repeat ABG

  17. Bedside • Hypoxia (O2sat<92% or PaO2<60 mmHg) • increase oxygen support until O2 sat >92% • careful with CO2 retainer (COPD, heavy smoker), O2sat ~90% • nasal cannula face mask venturi mask non-rebreather dual flow BiPap endotracheal intubation • repeat ABG

  18. Bedside • Hypoxia (O2sat<92% or PaO2<60 mmHg) • increase oxygen support until O2 sat >92% • careful with CO2 retainer (COPD, heavy smoker), O2sat ~90% • nasal cannula face mask venturi mask non-rebreather dual flow BiPap endotracheal intubation • repeat ABG

  19. Intubation??? • 12<RR>30/min • inability to protect airway • change in MS • paradoxical breathing • pH<7.35 • normal pH with tachypnea • PaO2<60 • PCO2>50 • Full Code • when you think it’s needed

  20. Causes of Shortness of Breath • A quick review

  21. Acute CHF • Hx of CHF or cardiac disorder, orthopnea/PND, + I/O, weight gain • signs of fluid overload (JVD, insp crackles +/- pleural effusion, systolic murmurs, + HJR, edema) • chest xray • decrease preload: sit patient up, oxygen, furosemide, NTG, morphine • look for cause of CHF

  22. Causes of CHF • CAD • HTN • valvular heart disease • cardiomyopathies • pericardial disease • MI • Fever, infection • dysrhythmia • PE • NSAIDS • anemia

  23. Pulmonary Embolism • Tachypnea, tachycardia and chest pain, Virchow’s triad (e.g. hypercoagulable state, immobility, vein injury), History of DVT • Pleural rub, pleural effusion, lower extremity with edema/palpable cord/calve tenderness • Stat ECG (S1Q3T3), stat CXR, stat CTA chest, echo, LE Doppler, d-dimer • Heparin vs LMWH, IVC filter, thrombolysis if in shock (call senior resident) • ICU transfer if with low oxygen saturation +/- intubation

  24. Pneumonia • cough productive of purulent sputum, fever/chills, pleurisy, +/- immunocompromised • leukocytosis, bandemia, CXR • sputum GS/CS, Strep/Mycoplasma/Legionella Ag, blood culture • antibiotics (refer to guidelines)

  25. Bronchospasm (Asthma/COPD) • tobacco abuse, steroid use, intubation history, precipitating factors, anaphylaxis • diffuse wheezing, prolonged expiration, loud P2 • somnolence, pulsus paradoxus, cyanosis, accessory muscle • CXR, ABG, spiromtery, pulse ox • oxygen, aerosols, steroid, antibiotics

  26. Always remember... • Call your senior resident if you need some assistance. • Perform proper hand-offs and sign-out

  27. CLINICAL PROBLEM SOLVING WHEN YOU’RE ON CALL • How to work-up and manage • Shortness of Breath

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