Case 1

A 27 yr old woman who is 1 week post-partum presents complaining of chest pain. On further questioning pain is pleuritic Associated with some breathlessness No sputum, no fever, no trauma No cardiac risk factors

On examination she is anxious, HR 100, RR 20, SaO2 97

Case 1

CXR NAD ECG sinus tachycardia ABG pH 7.47 O2 80

CO2 35 HCO3 19

What is your differential diagnosis?

What is the most likely diagnosis?

It is the 8am morning handover, what are you going to say and what is your plan

DDXPE, pneumothorax, pneumonia,

Most likely – PE

Case 1 8am handover round – Using ISBAR tool to handover

Identity – Patient’s name, 27 yo female in Bay 12

Situation – Patient referred by GP, arrived by ambulance, and I think she needs to have Pulmonary Embolism excluded

Background – post partum

Assessment – features consistent with PE e.g sinus tachycardia, no other diseases found, tests including CXR normal

Request – I would like to organise a CTPA, and when the result is available, refer to medical registrar if positive. If negative, I think could go home if stable and pain settles.

I could discuss with the medical team before handing over to the next doctor, but the CTPA result will define the management.

Case 1

CT PA Pulmonary embolism

confirmed Management

Referral to medical team Consider testing for

predisposition to clots Anticoagulation Explain to patient Follow up plan

Case 2

A 45 yr old man presents with increasing shortness of breath. He is hypoxic on room air and unable to lie down. He has a past history of chronic renal failure (on dialysis), NIDDM, Hypertension and peripheral vascular disease.

On examination he has signs of moderate pulmonary oedema, he is pain free and normotensive.

Image – describe this CXR

Case 2 questions

What are the appropriate initial investigations

What are the likely aetiologies of his oedema

Who do you need to speak to?

Tests Bedside

What can be done in the department?

Bloods Send these off, when

obtaining IV access

Radiology CXR, preferably in the

department

Questions 2

The ECG shows no acute changes and the patient is stable with a Sat of 93% on Oxygen, bedside troponin is normal

What is the most appropriate management In emergency Definitively Discuss with the unit who looks after him, e.g the

renal unit, because after initial management of potassium it is likely that urgent dialysis is what is required.

Case 3

A 19 yr old presents complaining of severe shortness of breath after running around the lake. He has a past history of similar symptoms but they usually settle spontaneously. On examination his RR is 30, he is alert and orientated. Saturation on air 100%

What is the cause of his condition? What will you look for on history and

examination?

History – sounds like asthma

respiratory distress precipitating factors past asthma indicators

of severity life threatening events ICU/ intubation oral steroids in last 6/12

medications/smoking other past history

In addition to asthma, what serious causes should be considered? HOCM Paroxysmal SVT or AF Pneumothorax (not likely

given recurrent episodes but always worth considering)

ExaminationLook for…

Respiratory distress speech use of accessory muscles chest movement & air entry wheeze duration and distribution more important

than volume pneumothorax

signs of hypoxia agitation, confusion, cyanosis, coma

Investigations

Bed side PEFR counting test

CXR only if suspect: pneumothorax pneumonia severe disease

ABG if Sat<92% on RA

Management options

Airway oxygen BIPAP/CPAP

bronchodilators B agonists anticholinergics aminophylline magnesium ketamine

Management options

steroids What would you use in this case?

Mild exercise induced asthma

B agonists via MDI & spacer Inhaled or oral steroids asthma plan and follow up Where do you find asthma action plans? What modes of delivery exist for B agonists

and what is their efficacy? What are the side effects?

B agonists

MDI & spacer droplets in critical size range cheap home same as hospital

nebuliser delivery depends on

gas flow volume construction & maintenance temperature

only 55% nebulised, 18% inhaled

B agonists intravenous side effects

tachycardia tremor hypokalaemia hyperglucaemia lactic acidosis

Case 4

A 40 yr old male collapses in his home, he is a business man and has recently returned from a overseas business trip

On examination he is now conscious alert HR 110 RR 20 BP 90/60 SaO2 90

Case 4

CXR NAD ECG sinus tachycardia,

RBBB, ST depression V1, V2

Case 4

ABG pH 7.35 O2 70 CO2 30 HCO3 17

The patient remains hypotensive, tachycardic and unwell

The most likely diagnosis is PE

The patient is referred for a CTPA

What are the possible outcomes from here?

Case 4

the patient arrests in the CT scanner

ECG shows sinus rhythm pulse remains non-palpable

Outcomes of arrest caused by PE.

http://www.ncbi.nlm.nih.gov/pubmed/10826469

Case 5

A patient presents with sudden onset of SOB that woke him from sleep. He has no chest pain, but is quite distressed and unable to lie flat and finds the oxygen mask claustrophobic.

He has a past history of hypertension, smoking, no history of ischaemic heart disease

O/E moderate to severe pulmonary oedema, hypoxic on 6lt oxygen, hypertensive, agitated.

Case 5 questions

What are the appropriate initial investigations What are the likely causes for his pulmonary

oedema What are the appropriate emergency

treatments

Case 6

A 13 yr old with a past history of atopy, presents with increasing SOB. She has had a URTI for the last 3/7, and now has 1/7 of increasing SOB not responding to home therapy. On examination she has SOB at rest, marked wheeze, she is able to give a limited history pausing frequently to breathe.

What other information do you require? What is your assessment? What is your initial therapy?

Case 6; Moderate asthma

Further history treatment at home?

Normal treatment? Past history asthma

indicators of severity PEFR (normal PEFR)

Who manages the asthma?

Any asthma education?

Management Initial

therapy B agonists 3 doses over 1/24

oral steroids reassess Asthma stickers in our

Emergency Department what are the indications

for admission?

Moderate asthma admission PEFR <75% predicted on arrival Sat < 92% on air 1/24 post therapy PEFR < 60% predicted 1/24 post therapy

Case 7 A 25 yr old with a history of mild asthma

presents from her work place after a minor fire. She presents now with rapidly increasing SOB. The ambulance have given her 4x nebulisers of salbutamol in transit with little relief. She is tachypneoic, tachycardic, quite agitated and refuses to lie down to be examined. She is unable to give any history due to her dyspnoea

What is her diagnosis? What further information do you require and

what is your management?

History

current illness baseline function important to assess management

& prognosis duration symptoms risk factors LFT & response to B agonists maintenance therapy including steriods normal activity levels home oxygen

intercurrent illness

Examination accessory muscle use cyanosis hypoxia precipitating factors

infection bronchospasm LVF/IHD sputum retention

what investigations?

Severe Asthma

PEFR<40% Sat <92% RA ABG CO2 important indicator

normo/hypercarbia indicator of exhaustion

management oxygen continuous B agonist +/- ipratropium intravenous steriods monitor

vitals,Sats,GCS

Severe asthma not responding intravenous B agonists BIPAP/CPAP ?theophylline Intubation

Ketamine induction agent of choice bronchodilator doesn’t reduce respiratory drive

Case 8 A 60 yr old man presents with 1/52 of

increasing SOB. He has had a mild URTI for 10/7. He tells you he has had asthma for many years, but the puffers don’t seem to help much. He still smokes 20 cigarettes per days and becomes annoyed when you suggest that this will make his asthma worse.

What is his likely diagnosis?

Case 8 Investigations Saturation & PEFR ECG looking for ischaemia ABG

useful to identify acute from chronic CO2 10mmHg - HCO3 1 upto 30mmol acute CO2 10mmHg - HCO3 4 upto 36mmol chronic

CXR if unwell to identify precipitants FBE

WCC infection or steroids polycythaemia indicator of chronic hypoxia

What is your management?

Case 8COAD management largely irreversible disease small improvements may give significant

symptomatic relief manage as per asthma CO2 retainers

rare loss of hypercapnic drive low FiO2

NIPSV reduced work of breathing improved V/Q reduces incidence of intubation

patients with poor pre-morbid function (FEV1<25%) <50% weaned within 4 months

Additional therapies aminophylline

theoretically good bronchodilator respiratory stimulant improves diaphragmatic function

problems pro-arrhythmic no proven benefit over other therapies

what are your admission criteria?

COAD admit or discharge? depends on

pre-existing disease severity of exacerbation,

hypoxia reversible precipitants response to therapy social & medical

supports ability to return if

deteriorates

Medical registrar may see the patient hours after you see them, late at night, condition may change.

“how far can you walk, what activities of daily living can you do/not do?”

Case 9

A 57yr old woman presents complaining of chest pain and shortness of breath she is currently under going chemotherapy for breast cancer.

On examination she is febrile 38º , HR 110 RR 24 BP 95/60 SaO2 90

Case 9

CXR LUL consolidation ECG sinus tachycardia ABG pH 7.35 O2 70

CO2 45 HCO3 22

Case 9

you admit the patient for treatment of her LUL pneumonia, she collapses in the toilet unconscious unresponsive

ECG shows sinus rhythm without palpable pulse

This is Pulseless Electrical Activity/EMD arrest

Could the presentation be due to PE? Yes

Can PE produce CXR findings that mimic pneumonia? Yes

Case 10

A patient presents via ambulance with severe central chest pain, agitation, SOB and hypoxia on 10lt oxygen.

Examination reveals a very agitated, distressed patient. He is hypoxic on high flow oxygen, hypotensive and tachycardic.

The monitor shows ST elevation in lead 1

Questions

What are the appropriate initial investigations What is the likely diagnosis What are the appropriate emergency

treatments What is the appropriate disposition and

further management

Image gallery – describe and give likely diagnosis

Diagnosis?

Diagnosis

Diagnosis

Describe this CXR

Emergency Department HMO education series 2012