Transcript CRANA Remote Emergency Care Programme

The Short of Breath Patient
Outline
Differential Diagnosis
Assessment
Investigations
Management
Specific Treatments
Summary
Causes ?
Differential Diagnosis
Asthma / COAD
Pulmonary oedema
Pulmonary embolism
Pneumonia / “chest infection”
Pneumothorax
Chest trauma
NON-respiratory disease (DKA!!!)
Assessment
Look
Resp Rate, effort and symmetry
Colour
Listen
Breath Sounds
Feel
Trachea
Pulse
Assessment
Past History
Previous episodes, medications?
Current Episode:
Precipitants, rapidity of onset?
Associated symptoms?
Initial treatment and response?
Examination
Primary survey / ABCs
Resuscitation
Oxygen, oxygen, oxygen
Secondary survey
Definitive treatment
Look at the Patient
Look at the patient from a distance
Posture, speech
Air hunger
Anxiety / conscious state
Pain limiting movement
Look at the chest from a distance
Respiratory rate
Even movement
Flail segments
Retractions or “tracheal tug”
Listen to the Patient
Speech
Stridor or Wheeze
Absent breath sounds?
Crepitations or crackles
Rubs
Touch the Patient
Trachea Midline?
Fractured Ribs?
Surgical Emphysema?
Pulse rate, BP, paradox?
Respiratory Distress
How bad are they?
How do you know?
What do you look for?
Respiratory Distress
Mild
Mod.
Severe
Mental
No
No
Yes
Speech
Sentences
Phrases
Words-Nil
Colour
Normal
Fatigue
No
Peripheral
Cyanosis
Mild
Per. & Central
Cyanosis
Yes
Chest
Normal
Accessories
Movement
Pulse
<110
100-120
>120
Wheeze
Moderate
Loud
Soft
“Investigations”
Peak Flow
Monitor trends and response
“Counting” test if no PEFR meter (20)
Pulse oximetry
ECG
AMI
PE
“Investigations”
Blood gases
Oxygenation and ventilation
Acid base status
Chest x-ray
Utilise early if available
Often provides diagnosis
Full blood Count
Anaemia
Infection
“Investigations”
U&E
BNP
Cardiac Markers
CKMB
Myoglobin
Troponin 1
“Investigations”
“Capnography”
Look at the patient!
The tiring patient has an increasing CO2
They develop:
A far away look
Eyes roll back
Sweat
Not answering questions any more
Quicker than blood gases
Respiratory Distress
Mild
Mod.
Severe
PEFR
>60%
40-60%
<40%
Sats
>94%
90-94%
<90%
pO2
Normal
>8kpa
<8kpa
pCO2
Normal
<5kpa
>5kpa
Beware the hypoxic patient with normal CO2!!!
Treatment
Non-Oxygen Therapy?
Reassurance and explanation
Better airway if required
Better posture: On side, sitting up
“Antidotes”...drug induced problem?
Not loss of “Hypoxic drive”?
Specific therapy for diagnosis
Oxygen
Hypoxia due to numerous causes
Not all primarily lung related!!
Impairs function of all organs
Brain, heart, kidneys, lungs
Hypoxia leads to restlessness!!!!
(Sedation is not a Rx for hypoxia!)
Oxygen can be life saving
DON’T withhold if “hypoxic”
Oxygen Toxicity
Many “toxicities”
Primary problem is “loss of hypoxic drive”
Balance between hypoxia and
hypercapnia!!
Consider patient’s “normal hypoxia”
Oxygen Therapy
Intranasal O2 prongs
Maximum 2 lit/min
Provides about 24% O2
“Hudson” type mask
Minimum 6 lit/min
Prevents any CO2 retention
Oxygen Therapy
“Venturi”type mask
More accurate O2 % delivered
Respiratory Support
CPAP
Continuous Positive Airway Pressure
Recruits collapsed alveoli
Useful in pulmonary oedema especially
“Pseudo-CPAP” with bag and mask
Respiratory Support
Intubation and Ventilation
The “ultimate control” in respiratory
failure
Case 1.
70 year old male
History of IHD
Acute SOB, sweaty, chest pain
Tachycardia, tachypnoea
Difficulty talking, altered mentation
Creps to midzones
Pink frothy sputum
What is wrong?
Acute pulmonary oedema..
What’s the treatment?
Acute Pulmonary Oedema
Sit upright
High flow Oxygen
IV Frusemide 1mg/kg
“Vasodilators” – GTN infusion
CPAP
Treat the precipitant
M.I.
Arrythmia
Case 2.
45 year old female smoker
Sharp left sided chest pain
Fevers, sweats and rigors
Yellow sputum
Tachycardiac, tachypnoea
Hypotensive
Coarse creps and bronchial breathing
What’s the likely diagnosis
Infection, ?? pneumonia.
What’s the treatment
Pneumonia
Oxygen
IV antibiotics ASAP
IV Augmentin 1.2gms
IV Klacid 500mgs
Cultures if possible
But don’t allow to delay antibiotics!
Physiotherapy
Posture
Bronchodilators (Salbutamol 5mgs
Nebuliser)
Case 3.
60 year old male smoker
Increasing SOB 2 hours
Tachycardia, tachypnoea
Pale, sweaty
No creps, no wheezes
No air entry detectable!!!!
What’s the diagnosis?
COAD / asthma / emphysema…
What’s the treatment?
Asthma / COAD
Reassurance
Oxygen
Continuous salbutamol nebs 5mgs +/500mcgs Atrovent
IV steroids – Hydrocortisone 200mgs I.V.
Aminophylline infusion (little/no data to
support usage)
Consider Magnesium infusion
Cosider Salbutamol infusion?
Case 4
26 year old man
Sudden onset right sided chest pain
Shortness of breath at rest
Difficulty talking
Tachycardia, Hypotensive, Hypoxic
Pneumothorax
Tension pneumothorax
Respiratory distress
Asymmetrical chest movement /
sounds
Tracheal deviation
Mediastinal shift
Distended neck veins
Cardiovascular collapse
Needle Thoracostomy
Temporary
measure
Wide bore cannula
2nd interspace,
MCL
Remove sylet,
leave cannula in
Prepare for
definitive ICC
Case 5
53 year old woman
Cigarette smoker
Hx of Ovarian Carcinoma
Sudden onset shortness of breath
Asociated chest pain
Palpitations
What’s the diagnosis ?
Pulmonary embolus
Treatment
High flow 02
Low Molecular weight Heparin (Clexane
1mg/kg)
Warfarin 10 mgs
Consider thrombolysis
Consider embolectomy
+/- inotropic support
Questions
?
Summary
Past history helpful
Severity can be assessed at the
bedside
Don’t forget to examine the
chest
Summary
Therapy may have to start
before the diagnosis is confirmed
Give complete Rx: more than
just oxygen
Croup
Steroids standard care
Route of administration not
Inhaled, oral or parenteral
Adrenaline Neb (1:1000) 5mg
in 5ml
Intubation rarely
Open Pneumothorax
Sucking chest wound
Close the wound!!
Seal with opsite, dressing etc.
Intercostal catheter
Chest Trauma
Penetrating trauma
Lung, cardiac, vascular, GIT injuries
Abdominal injuries too!
Blunt trauma
Don’t need to break ribs etc
Pulmonary contusion
Aspiration