ED trainingRespiratory/

patient with dyspnea

Dr Jaycen Cruickshank

Emergency Medicine Training Hub

Ballarat & Grampians Region

2012

Respiratory - dyspneaLearning objectivesThe respiratory session will examine contrasting clinical cases of dyspnoea that will illustrate the

principles of diagnostic reasoning. lmportant physical findings that help discriminate different causes of dyspnoea will be discussed along with appropriate initial investigations.

Learning objectives Be able to describe the differences and similarities in the medical history, physical examination

and investigations of common or life threatening causes of dyspnoea. To manage asthma and pneumonia using best practice guidelines To be able to use the Wells score & PERC rule in diagnosis of PE

Pre reading Hughes T & Cruickshank J. Adult Emergency Medicine at a Glance. Chichester, West Sussex,

UK : John Wiley & Sons, 2011.  Chapter 36 Shortness of breath. Chapter 7 Blood gas analysis.

Other learning resources Relevant clinical clinical guidelines at Ballarat Health Services:

Refer to ED lecture series and self directed workbooks

Other learning resources

Other learning resources http://www.mdcalc.com/wells-criteria-for-pulmonary-embolism-pe/ Wells et al. Excluding pulmonary embolism at the bedside without diagnostic imaging:

management of patients with suspected pulmonary embolism presenting to the emergency department by using a simple clinical model and d-dimer. Ann Intern Med. 2001 Jul 17;135(2):98-107. http://www.ncbi.nlm.nih.gov/pubmed/11453709

Written asthma action plans. http://www.nationalasthma.org.au/managing-asthma/controlling-your-asthma/written-asthma-action-plans

Pneumonia severity scoring systems for community-acquired pneumonia in adults (Appendix 2.4) http://jasper.tg.com.au/complete/tgc/abg/8052.htm

http://lifeinthefastlane.com/2009/11/a-classic-respiratory-case/ 

Preparation slidesThese may be pre reading +/- presented by teacher

The first part of this presentation is designed to be pre reading.

Learners are encouraged to do some reading before the tutorial

The slides may be presented briefly at the start of a session to recap

Your hospital should have some clinical guidelines which will provide relevant local information

Emergency Department HMO education series 2012

How do we make a diagnosis in a patient with dyspnea?

History Cardinal features Associated features Risk factors (for diseases), past history (known

diseases), respiratory reserve “what can do usually?”

Examination findings Suitable/targeted investigations

CXR, ECG, ABG’s, basic bloods Lung function, CT, VQ, exercise test, echo

Emergency Department HMO education series 2012

A focussed history determines both diagnosis and severity. SOB + associated symptoms

suggests a cause or differential diagnosis

SOB + Pleuritic pain= Pneumonia, pneumothorax

SOB + wheeze = Asthma, COPD

SOB + stridor = Inspiratory obstruction e.g croup

SOB + fever/cough/sputum = Pneumonia, other infection

SOB + haemoptysis Upper airway cause, Pneumonia, PE,

cancer, vasculitis

The severity of symptoms E.g is the person breathless at

rest, on exertion Certain features aid diagnosis Acute onset Pneumothorax, PE, AF, APO, asthma Gradual onset or with exertion Cardiac cause, chronic anaemia Worse at night, or lying down Cardiac failure

Background history Would you prefer to know risk factors for disease or known diseases?

Exacerbations of known diseases are common and the diagnostic challenge is likely to focus on precipitant, and the severity of the consequences of the exacerbation

Ask about Medications, including doses, compliance, recent changes Who normally looks after the patient and where Is there access to a good summary of recent treatment – think the GP, specialist clinic

letters, recent admissions As you build up a differential diagnosis, ask questions that are relevant to each

differential e,g I am thinking PE, so I will ask about recent travel, perhaps use the Well’s criteria I am thinking pneumonia, I might ask about hospital vs community acquired,

immunosuppresion, contacts, birds, known recent outbreaks e.g Legionella I am thinking what should I not miss, e.g cardiac causes This type of approach to differential diagnoses is often helpful when working through

a list of possible diseases.

Emergency Department HMO education series 2012

Paediatrics A quick reminder that for

paediatric assessment, there are resources available to assist with normal values

Hypoxia needs immediate correction, remember cyanosis a pre terminal sign in children

Most of the examination can be completed without O2 sats or a stethoscope using observation

Emergency Department HMO education series 2012

You need to be familiar with this for winter. Standardised way to assess, present, refer kids.

The Royal Children’s clinical guidelines are an excellent resource to look up while working in the Emergency Department.

http://www.uhs.nhs.uk/Media/suhtideal/TopNavigationArticles/SkillsForPractice/ClinicalSkills/paediatricassessment.pdf

Recognition of the seriously ill child http://paeds.org/apls/aplsrecog.html the structured approach to the seriously ill child

http://www.paeds.org/apls/aplsapp.html

Clinical cases to demonstrate

We have a very thorough powerpoint presentation that contains more detail, a very methodical approach.

Highly recommended. The rest of this presentation will contain

some cases. A further series of cases will be presented at

the actual teaching session.

Emergency Department HMO education series 2012

Case A

A young man presents to the Emergency Department via ambulance

He complains of sudden onset of SOB. Present for a few hours and now quite

severe.

Emergency Department HMO education series 2012

Further history

Previously well, smokes 10 cigarettes/day Left sided chest pain

Moderate Pleuritic Started with the SOB

Is there anything else you would like to ask? What is your ddx?

Emergency Department HMO education series 2012

Differential diagnosis

Pneumothorax Arrhythmia

Pulmonary Embolism

Asthma (less likely)

Much less likely Pneumonia

Not to be mentioned before all organic causes considered anxiety Imagine that being your

diagnosis and you missed the pneumothorax…

Emergency Department HMO education series 2012

Examination findings Looks unwell, quite

distressed with WOB RR 26, HR 125 SR, BP

80/60, afebrile Saturation 93% RA (room

air) Trachea midline chest expansion on the

left Hyperesonant percussion

note on the left air entry left lung

What is going on? Is this serious? What is your immediate

management?

Emergency Department HMO education series 2012

Describe this CXR… ideally this intervention before this CXR…

Emergency Department HMO education series 2012

Diagnosis and management?

Initial therapy? Who will help you?

Where you are working, will you call a MET, ask for senior help?

Urgent chest tube (this may have even been done without a CXR if the patient was unwell enough)

Emergency Department HMO education series 2012

Describe this CXR

See notes for report

Emergency Department HMO education series 2012

Describe this CXR

Emergency Department HMO education series 2012

Case B

Young man Brought to the ED by

his partner Progressive SOB over

48 hours. Now present at rest

How is your differential diagnosis altered by the gradual onset? Asthma Pneumonia Other?

Emergency Department HMO education series 2012

Further history & examination

Wheeze Dry cough Recent URTI Childhood asthma (age

3-12), hay fever No cardiac history No risk factors for PE

RR 24, HR 110 SR, BP 110/70

Sat 97% RA Widespread wheeze

(what causes this sound?)

Emergency Department HMO education series 2012

Investigations If the CXR is normal… Peak Flow 300/min (how does this

help us?) ABG ph 7.5/CO2 30/O2 70/HCO3

23 What do the blood gases show? How severe is the problem

What if the CXR not normal, as seen on right

Does it exclude asthma?

Emergency Department HMO education series 2012

Diagnosis is asthma:

The treatment plan is easy, but can you document it well? Bronchodilators, corticosteroids, oxygen

Describe the stickers used to standardise prescribing in the ED at Ballarat Health Services

Describe a safe asthma discharge plan What are asthma action plans? http://www.nationalasthma.org.au/health-professionals/tools-for-primary-care/asthma-action-plans/asthma-action-

plan-library

Emergency Department HMO education series 2012

What scoring tools for pneumonia?

CURB-65, SMARTCOP? How do scoring tools help predict:

Need for admission, and appropriate ward Antibiotics and route Mortality

Is it acceptable to write clinical notes on a patient with a diagnosis of pneumonia and not document severity using one of these tools? No

Various website and apps can assist you in remembering them. www.mdcalc.com

Further cases…

To be presented at the teaching session. See part 2 & 3