Ed training respiratory patient with dyspnea
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ED training Respiratory/ patient with dyspnea. Dr Jaycen Cruickshank Emergency Medicine Training Hub Ballarat & Grampians Region 2012. Respiratory - dyspnea Learning objectives.

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Ed training respiratory patient with dyspnea

ED trainingRespiratory/ patient with dyspnea

Dr Jaycen Cruickshank

Emergency Medicine Training Hub

Ballarat & Grampians Region

2012


Respiratory dyspnea learning objectives

Respiratory - dyspneaLearning objectives

The 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

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 slides these may be pre reading presented by teacher

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


How do we make a diagnosis in a patient with dyspnea

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

A focussed history determines both diagnosis and severity.

Emergency Department HMO education series 2012


Background history

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.


Paediatrics

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

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

Emergency Department HMO education series 2012


Clinical cases to demonstrate

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.


Case a

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

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…

Differential diagnosis

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?

Examination findings

Emergency Department HMO education series 2012


Describe this cxr ideally this intervention before this cxr

Describe this CXR… ideally this intervention before this CXR…

Emergency Department HMO education series 2012


Diagnosis and management

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

Describe this CXR

  • See notes for report

Emergency Department HMO education series 2012


Describe this cxr1

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?

Case B

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?)

Further history & examination

Emergency Department HMO education series 2012


Investigations

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

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

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

Emergency Department HMO education series 2012


Further cases

Further cases…

  • To be presented at the teaching session.

    • See part 2 & 3


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