Transcript POST NATAL RESPIRATORY DISTRESS

POSTPARTUM RESPIRATORY
DISTRESS
HAZHIR HEIDARI BEIGVAND
EMERGENCY PHYSICIAN
EMERGENCY WARD MANIFESTATION:
CHIEF COMPLAINT:
SEVERE DYSPNEA
PRESENT ILLNESS:
THE PATIENT IS A 32 YEARS OLD WOMAN WHO
HAS UNDERGONE C/S 5 DAYS AGO AND HAS A
BABY GIRL NEONATE,SHE SUFFRED FROM
ACUTE ONSET DYSPNEA WHICH LEAD TO
SLEEP INTERRUPTION IN 3AM.
FIRST SECONDS MONITORING
FINDINGS:
PAST MEDICAL HISTORY:
PATIENT HAS UNDERGONE C/S 5 DAYS AGO.
BABY’S BIRHT WEIGHT IS 2550 GRAM.
THE PATIENT HAS HAD A PROBLEM IN LAST 10
YEARS IN NECK AREA,SHE DOESN’T KNOW
THE NAME OF DISEASE,BUT HER MOTHER
CONFIRMS IT WAS:HODGEKIN
DRUG HISTORY &HABITUAL HISTORY:
DRUG HISTORY:
CHEMOTHERAPY DUE TO (PROBABLY)
HODGKIN’S DISEASE ABOUT 10 YEARS AGO
NO OTHER DRUG EXCEPT VERY OCCASIONAL
TABLETS FOR SLEEP(LORAZEPAM,….)
HABITUAL HISTORY:
OCCASIONAL SOCIAL SMOKER
NO ALCOHO,NO OTHER ILLICIT DRUGS
P/E AND CLINICAL FINDINGS:
GENERAL APPEARANCE:
AN OBESE YOUNG WOMAN WHO IS OBVIOUSLY
SUFFERING FROM RESPIRATORY DISTRESS.
VITAL SIGNS:
BP:121/61 PR:117/MIN RR:56/MIN T:38.6
ENTRANCE SPO2:80% BY O2 SUPPLY NASAL
CANULA:84% WHICH ULTIMATELY
INTERCHANGED TO MASK DELIVERY:88%
PHYSICAL EXAM CONT:
H&N:TACHPNEA AND HYPERVENTILATION IS
OBSERVED
CHEST:BREATHTS ARE FAST AND SHALLOW
REMARKABLE SWEATING INCHEST AND AXILLARY
AREA IS OBSERVED.
HEART AUSCULTATION:S1;S2
NO REMARKABLE AUSCULTATORY FINDING
IN LUNG EXAM(PROBABLY DUE TO SHALLOW
AND SUPERFICIAL BREATHS AND PATIENT’S
OBESITY.
PHYSICAL EXAM CONT:
ABDOMINAL: RESPIRATIONS SOMETIMES ARE
ABDOMINAL.NO TENDERNESS AND
ORGANOMEGALY IS DETECTED.(UNRELIABLE
ABDOMINAL EXAM DUE TO OBESITY)
EXTREMITIES AND NEUROLOGY:
NO POSITIVE FINDING
PRIMARY PARACLINICAL FINDINGS:
WBC:11700 /RBC:4.8/HG:12.3/MCV:81
ESR:61/NA:137/K:3.4/BUN:27/Cr:0.9
PT:14/PTT:21/INR:1.1
CXR:NO REMARKABLE FINDING
D-DIMER:POSITIVE(QUALITATIVE/NO ACCESS TO
QUANTITATIVE D-DIMER)
ELECTROCARDIOGRAPHY:
WHAT IS THE DIAGNOSIS?
WHAT IS THE NEXT STEP AT THIS
STAGE?
CLINICAL TREND AFTERWARDS:
PATIENT UNDERWENT CRITICAL MANAGEMENT
AND CONTINUOUS CARDIAC MONITORING
AND PULSEOXIMETRY.
BASED ON PRIMARY EVALUATION SOME
THERAPEUTIC RENDER APPLIED AND
COMPLEMENTARY DIAGNOSTIC REQUESTS
WERE FOLLOWED SIMULTANEOUSLY.
CLINICAL TREND AFTERWARDS(CONT):
AFTER ABOUT 3 HOURS OF TREATMENT
PATIENT’S DISTRESS GRADUALLY RELIEVED.
BP:128/73 PR:96 RR:21/MIN SPO2:94%(10LIT
MASK SUPPLY)
DESPITE MEDICAL STAFF EXPLANATIONS
ULTIMATELY AFTER ABOUT 7 HOURS OF
ADMISSION PATIENT LEFT THE HOSPITAL BY
CONSENT.
MEDICOLEGAL DISCUSSION:
IS THIS LEGALLY ACCEPTABLE?
WHAT SHOUD BE DONE?
WHEN YOU ARE FACING A PATIENT WHO HAS A
POTENTIALLY LIFE THREATENING CONDITION
AND THEY ARE INSISTING TO LEAVE THE
HOSPITAL.
PROFESSIONAL RESPONSIBILITY DISCUSSION?
LEGAL RESPONSIBILITY DISCUSSION ?
(ACCORDING TO EBM AND NATIONAL LAW)
DYSNEA MANAGEMENT AS
ACARDINAL MANIFESTATION:
BASED ON PRIMARY HISTORY AND PHYSICAL
EXAMINATION “INITIAL WORK UP IS APPLIED
AND THEN
“5 CATHEGORICAL” APPROACH
IS FOLLOWED:
INITIAL ASSESSMENT AND WORK UP:
COMPLETE INITIAL EVALUATION BY VITAL SIGNS
AND SaO2 THEN:
• Supplemental oxygen
• Cardiac monitor IV access
• Continuous waveform
• capnography
1-ASTHMA &COPD EXACERBATION:
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1. Inhaled beta-agonist
2. Steroids IV
3. Consider other adrenergics
4. Treat concurrent infection
5. Counsel smoking cessation
2-PULMONARY EMBOLISM:
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CHECK D-DIMER THEN:
1. Initiate anticoagulation with
IV heparin or subcutaneous
low-molecular-weight heparin
2. Consider systemic thrombolysis
if unstable
3. Consider interventional clot lysis
with pulmonary angiography
3- Cardiac,
obtain ECG
• A- Dysrhythmia: antiarrhythmics or cardioversion
• B-Ischemia: nitrates, ASA, pain
management, thrombolysis,
beta-blockade or PCA
C-BNP CHECK :AS A SETTLED DISCRIMINATOR
BETWEEN CARDIAC AND NON CARDIAC
DYSPNEA:Heart failure: diuretics, nitrates, ACEI
IV MORPHINE
4- Pneumonia,
infectious cause:
1. Initiate appropriate empirical
antibiotic, antifungal, or
antiviral medication promptly
2. Isolation if needed
3. Blood, sputum cultures
4- Anaphylaxis:
1. Secure airway when needed:
endotracheal intubation,
cricothyrotomy
2. Epinephrine IV (extreme), SQ
3. Steroids IV
4. Diphenhydramine IV
5. Inhaled beta-agonist
6. Consider inhaled racemic epinephrine, heliox
7. H1/H2 blocker IV
4-TRAUMA
BASED ON FAST EXAM RESULT:
1- Tension pneumothorax:
Immediate chest decompression
by needle or tube thoracostomy
2- Pulmonary contusion,
multiple rib fractures:
pain management
3- Inhalation injury:
early endotracheal intubation
REGARDLESS OF DIAGNOSTIC
MAMAGEMENT IF :
RESPIRATORY FAILURE
HAPPENED:
1. CPAP/BiPAP (short term) or
endotracheal intubation, and
mechanical ventilation
2. Treat underlying cause
PE DIAGNOSIS:
PULMONARY EMBOLUS
MANAGEMENT IN PREGNANCY:
CLINICAL FEATURES:
TRADITIONAL SIGNS&SYMPTOMS ARE
NONSPECIFIC,BECAUSE THEY HAPPEN IN
NORMAL PREGNANCY.
CESAREAN DELIVERY AND POSTPARTUM
COMPLICATIONS FURTHER INCREASE THE RISK
OF DEVELOPING A THROMBOEMBOLISM.
PE DIAGNOSIS IN PREGNANCY:
1-UP TO 24% OF DVTs ARE COMPLICATED BY PE.
2-DIAGNOSTIC TEST OF CHOICE IS:
US COMPRESSION:
SENSITIVITY&SPECIFICITY IS 95%&96%
RESPECTIVELY.
2-D-DIMER IS CHECKED BUT IS NOT AS VALUABLE
AS NON PREGNANT PATIENTS.
(IN LATTER GROUP HAS A HIGH SPECIFICITY &NPV)
TAKE HOME MESSAGE ABOUT PE
DIAGNOSIS IN PREGNANCY:
BECAUSE OF HIGH MORTALITY & MORBIDITY
IF GOES UNDIAGNOSED:
IN CLINICAL SUSPICION IMAGING STUDIES
SHOULD NOT BE WITHHELD BECAUSE OF FEAR
OF RADIATION EXPOSURE TO THE FETUS
MASSIVE
CAVITATION IN INFARCTED AREAS OF
LUNG TISSUE AFTER PE:
PE TREATMENT IN PREGNANCY:
BOTH TYPES OF ANTICOAGULATION THERAPY
ARE PERMITED,BUT:
UNFRACTIONATED HEPARINE IS
PREFERRED OVER LMWH IN
HEMODYNAMICALLY UNSTABLE CONDITION
WITH MASSIVE PTE
PTE DISPOSITION IN PREGNANCY:
NO DOUBT&DEBATE:
INTENSIVE CARE UNIT
PERC:PULMONARY EMBOLISM
RULE OUT CRITERIA
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BOX 88-2
1-Low pretest probability for PE by the treating clinician’s
2-unstructured estimate, plus:
Age less than 50
Pulse rate less than 100 beats/min
Oxygen saturation greater than 94%
No hemoptysis
No unilateral leg swelling
No recent major surgery or trauma
No prior pulmonary embolism or deep venous thrombosis
No hormone use
Pulmonary Embolism Rule-Out Criteria
(PERC Rule)
PE, pulmonary embolism.