Pitfalls in Shortness of Breath

Transcription

1 Pitfalls in Shortness of Breath Stuart Swadron, MD FRCPC FACEP Vice-Chair of Education and Program Director Department of Emergency Medicine Los Angeles County-University of Southern California Medical Center Massive Hemoptysis WHERE ARE YOUR FRIENDS?

2 Pitfalls in Shortness of Breath Agenda Tricky Aspirations Pitfalls in Shortness of Breath 1 Crashing Asthmatic Sweaty Can t Talk Tachypneic Tripoding THE LOOK OF DOOM Maximal O 2 (NRB) Inhaled Albuterol Inhaled Atrovent IV Steroids IV Magnesium SC Terbutaline THE KITCHEN SINK Maximal Rx

3 Theophylline Leukotriene Inhibitors Long Acting β2 agonists Heliox (maybe a bit harsh!) BiPAP CPAP THE GARBAGE BIN Not Indicated NON-INVASIVE VENTILATION Too Early Too Late KEEP IT SIMPLE! Etomidate Succinylcholine OPTIONS... Lidocaine Ketamine GO FAST! WHEN TO INTUBATE HOW TO INTUBATE

4 Reason #1 Mucous Plugs STILL TRYING TO DIE? BIG ET TUBE AGGRESSIVE TOILET Reason #2 Dehydration yekaterina yushmanaova 2003 STILL TRYING TO DIE? IV FLUID BOLUS

5 Reason #3 Breath Stacking STILL TRYING TO DIE? Squeeze Chest Low Vent Settings Reason #4 Barotrauma STILL TRYING TO DIE? Chest Tubes

6 1 Disconnect ventilator 2 Squeeze chest 3 Bilateral chest tubes 4 Fluid bolus Asthma Arrest Anesthetic Gases ECMO Summary DISPO TO THE OR! Pitfalls in Shortness of Breath Upright PA View 2 New News on Pneumos Typical Pneumothorax Visceral pleural line No vessels past line Density equal to other lung

7 Do You See A Pneumothorax? CT Shows Large Pneumothorax The Deep Sulcus Sign CT

8 The Deep Sulcus Sign The Deep Sulcus Sign The Deep Sulcus Sign Sharp Diaphragm Sign

9 Sharp Diaphragm Sign Double Diaphragm Sign 761 patients 103 pneumothoracies 57 were not seen on initial supine AP film! Ball CG et al. Am J Surg 189 (2005): Some Recent Literature Some Recent Literature

10 Pneumothorax in the supine patient Often missed on portable film Seeing vessels out to edges does not rule out Anterior in the lower thorax Signs: Deep sulcus Sharp Diaphragm Double diaphragm Summary I ve learned everything I know by screwing something up - S. Swadron

11 71 o with COPD Exacerbation Assault with a Deadly Weapon Before After Oops! Small (but real!) Septations

12 Before After More Oops! Another Septation Bulla vs. Pneumothorax Bullae are common in asthma and COPD Beware of a pneumothorax with non-anatomic contours Check an old chest x-ray if available Don t be afraid to ask for help! One You Wouldn t Miss Summary

13 Pitfalls in Shortness of Breath 3 NORMAL PNEUMOTHORAX Will Ultrasound be the Answer? The Great Masquerader Syphilis Endocarditis Tuberculosis Lupus Lyme Disease HIV Candidate Diseases Pneumonia? Candidate Diseases

14 57o smoker c cough, CP and SOB x 3d 57o smoker c cough, CP and SOB x 3d Pulmonary Embolus and the CXR Usually an abnormal x-ray but non-specific (e.g. elevated hemidiaphragm) Common abnormalities often attributed to pneumonia or simple atelectasis An infiltrate may be a Hampton s hump! Westermark s sign does exist! Multiple Pulmonary Emboli Summary

15 47o IVDU c SOB and Fever x 1d Multiple Cannonballs When you diagnose pneumonia, briefly consider Pulmonary Embolus Endocarditis Septic Emboli Tuberculosis Diffuse Alveolar Hemorrhage 67o with severe COPD exacerbation Summary

16 In COPD exacerbation, briefly consider Pneumothorax (but beware the bulla!) Pulmonary embolus Lobar collapse D-Dimer BNP Troponin Summary The SOB Blood Panel Causes Of SOB D Dimer BNP Troponin COPD PNA PE ACS CHF Others The Utopian Scenario Will the D-Dimer Save You? False positive with pneumonia/ sepsis COPD increases risk of PE Pitfalls of Biomarkers in SOB

17 How about the troponin? False positives with severe COPD False positives with PE (e.g. Doesn t indicate ACS) Does predict a poor outcome Pitfalls of Biomarkers in SOB How about the BNP? False positives with severe COPD False positives with PE (2º to right ventricular strain) COPD and CHF frequently co-exist A very low BNP rules out CHF but intermediate values may only raise more questions Pitfalls of Biomarkers in SOB CLINICAL FINDING Initial clinical judgment History Heart failure Myocardial infarction Symptoms Paroxysmal nocturnal dyspnea Edema Physical examination LR LR Chest radiograph Interstitial edema Alveolar edema Cardiomegaly ECG Atrial fibrillation Any abnormal finding BNP alone (pg/ml) Don t throw away your stethoscope Third heart sound Rales Lower-extremity edema Wang CS et al JAMA :1944 Predictors of CHF Pitfalls of Biomarkers in SOB

18 Pitfalls in Shortness of Breath Tricky Aspirations 4 Tricky Aspirations Yikes! Tricky Aspirations Tricky Aspirations Major Hemoptysis Major Chest Tubes Major Pneumothorax One Nail in the Coffin Tracheobronchial Tear

19 Tricky Aspirations Improvement with antibiotics & bronchodilators Tricky Aspirations 17 month old boy, sudden onset coughing Pneumonia seen on the X-ray Negative X-rays Failure to consider in adults Why Do We Miss the Diagnosis? Plain Film Series Tricky Aspirations Tricky Aspirations Right Lateral Decubitus Lateral Neck Plain Film Series Expiratory film Plain Film Series

20 Tricky Aspirations Tricky Aspirations Allan JS et al. Chest Surg Clin N Am 13 (2003) A Swallowed Coin in an Adult? Kavanagh et al. Clin Radiol (6): A Swallowed Coin in an Adult? LAC+USC Medical Center LEVEL 1 COCAINE ASPIRATION CENTER

21 Pitfalls in Shortness of Breath Agenda Thank you! 4 Tricky Aspirations