SOB. A Complaint With Many Faces

Transcription

1 SOB A Complaint With Many Faces Presented by : Dr. Chris Lee - PGY 2 ER Dr. Matthew Davis - Staff ER Physician, Interim Medical Director for Education

2 2 Shortness of Breath

3 Objectives Upon completion of this presentation, the paramedic should be able to: Describe comprehensive pre-hospital differential diagnoses of SOB, Distinguish between the common causes of SOB, and Apply pre-hospital SOB treatments to various patient care scenarios according to the Advanced Life Care Patient Care Standards. 3

4 Outline Outline common pitfalls when assessing SOB Develop a structured approach to SOB in the pre-hospital setting Review protocols available to treat SOB 4

5 Case 1 76 y/o F Hx of angina, COPD, MI with stent, DM Type 2 Has been getting progressively SOB since the holidays started Has trouble lying down, sleeps in a recliner, SOB always worse at night Still smokes 1/2 pack per day, puffers don t help T: 36.8, HR: 98, BP: 104/78, RR: 24, O2: 91% Auscultation: wheezes bilaterally *Wheezes = COPD* 5

6 Case 2 81 y/o M Hx of HTN, CAD, dyslipidemia, MI, stroke 6 months ago with speech/swallowing deficits Acutely SOB while eating dinner Has some pain with respirations, took nitro without any benefit T: 37.0, HR: 92, BP: 147/93, RR: 20, O2: 94% Auscultation: crackles at bases *Crackles = CHF* 6

7 Case 3 9 y/o M SOB for the past day or so Has been feeling generally unwell for a couple days, worst today, feels increasingly SOB Parents called because very fatigued, N/V, confused, complains of thirst Looks dehydrated, drowsy, hyperpneic T: 37.6, HR: 128, BP: 102/66, RR: 34, O2: 99% Auscultation: Normal breath sounds *Many causes of SOB* 7

8 Shortness of Breath Dyspnea Sensation of breathlessness and the patient s reaction to that sensation. 1 Imbalance of the perceived need to breathe, and the perceived ability to breathe. 2 8

9 O2 in Carotid Bodies Thoracic Cage Protection, inhalation, stretch receptors Diaphragm Inhalation 9

10 10 Negative pressure

11 11

12 O2 in Carotid Bodies CO2 out Medulla Oblongata Trachea Conduit, vocal structures Lungs Gas exchange Thoracic Cage Protection, inhalation, stretch receptors Heart Pump Diaphragm Inhalation 12

13 Foreign body Supraglottitis Vocal Cord Paralysis Croup Trauma Anaphylaxis Trachea Rib Fractures Flail Chest Thoracic Cage Metabolic DKA Renal Failure Electrolyte abnormalities Metabolic Acidosis Thyroid disease Obesity Pregnancy Ascites Intraabdominal infection/sepsis Abdomen Pulmonary Embolus Pneumothorax Asthma Aspiration Pneumonia Pleural Effusion Neoplasm COPD Inhalation injury ARDS Pulmonary Contusion Heart Lungs Pulmonary Edema Myocardial Infarction Cardiac Tamponade Pericarditis Valvular Disease Cardiomyopathies Dysrhythmia Diaphragm Ruptured Diaphragm Hiatus Hernia Diaphragm paralysis Hematologic CO Poisoning Acute Chest Syndrome Anemia 13

14 Treatable (pre-hospital) causes of dyspnea Trachea Foreign Body Croup Anaphylaxis Heart Cardiogenic Pulmonary Edema Cardiac Ischemia/Myocardial Infarction Dysrhythmia Lungs Pneumothorax Asthma COPD 14

15 Trachea Foreign Body Croup Anaphylaxis Child: not watched, missing objects Adult: while eating, taking pills Stridor, audible wheeze, coughing, vomiting, possible decreased BS *Stridor* *High risk story* Children, late fall/winter, 6 mo - 6 yrs, Viral illness prodrome Seal-bark cough, hoarse voice, stridor *Stridor* *Seal-bark cough* History of allergy, GI, Skin complaints, Possible exposure Angioedema, Urticaria, N/V, Possible shock, Wheezing, Cough, stridor *High-risk story* *Cluster of symptoms* 15

16 Trachea Foreign Body Croup Anaphylaxis BLS maneuvers if awake If arrested, can attempt removal If severe respiratory distress: Nebulized epinephrine IM epinephrine IV/IM diphenhydramine If arrested after removal, run medical cardiac arrest 16

17 Lungs Pneumothorax Blunt or penetrating thoracic trauma Spontaneous in tall, young men, also COPD Tension: accumulating air, compression of mediastinum Usually acute onset Chest pain, decreased BS unilaterally *Tension* ++ acutely ill, cyanotic, hypotensive *Acute, high risk story* *decreased BS unilaterally* Asthma History of atopy, Puffer use, Worse at night, Triggers: allergens, exercise, stress Cough, WOB, Air entry Diaphoresis, Wheezing *High-risk story* *wheeze* COPD Long pre-morbid course, Smoking, SOBOE, Chronic cough Cough, WOB, Air entry Wheezing, crackles Auto-PEEP, unwell appearance *High-risk story* *wheeze* 17

18 Lungs Pneumothorax Asthma COPD If tension: Needle thoracostomy *NO* CPAP MDI/Nebulized Ventolin CPAP MDI/Nebulized Ventolin 18

19 Heart Pulmonary Edema (Cardiogenic) MANY causes: Infarction, cardiomyopathies, valvular dysfunction, dysrhythmia, volume overload, ) Hx of: Heart issues, orthopnea, PND, SOBOE Often worse at night Auscultation: Crackles, wheezes, extra heart sounds, if R-sided failure: JVP, leg edema *High-risk story* *Crackles bilaterally* Dysrhythmia Brady Tachy Hx of conduction problems SOB, syncope EKG changes (SSS, AV blocks, ) *EKG* Hx of similar episodes SOB, Palpitations EKG changes (A.Fib/Flutter, AVNRT, ) *EKG* Cardiac Ischemia Chest pain, associated SOB, worse with exertion History of angina, nitro CVS and Resp N, may have extra heart sounds EKG changes possible *High-risk story* *EKG* 19

20 Heart Pulmonary Edema (Cardiogenic) SL Nitroglycerin If in setting of STEMI and shock: IV Saline IV Dopamine Dysrhythmia Brady Tachy If unstable: Atropine BHP guidance: Transcut. Pacing Dopamine AVNRT/AVRT Valsalva Adenosine BHP guidance: Widecomplex Amiodaro ne Lidocaine Cardiovers ion Cardiac Ischemia PO ASA SL Nitroglycerin IV Morphine If in setting of STEMI and shock: IV Saline IV Dopamine 20

21 21 History, History, History

22 22

23 Start with history Start with protocols 23

24 Case 4 68 y/o M Hx of COPD, CABGx3, anxiety, HTN, DM2 Cough, SOB x 2 weeks, now spiking fever Greenish sputum, wife calls because now confused, GP 5 days ago put him on unknown antibiotic T: 38.6, HR: 117, BP: 96/74, RR: 25, O2: 89% Auscultation: crackles and air entry RLL, wheezes B/L *Multiple diagnoses can coexist* 24

25 25 Questions?

26 References 1. Marx JA, Hockberger RS, Walls RM, Adams JG, Barsan WG, Biros MH, et al., editors. Rosen s Emergency Medicine: Concepts and Clinical Practice. 7th ed. Philadelphia: Mosby Elsevier; Rawy A. Dyspnea [internet]. [Update Jul 2008, Cited Mar 2013] Available online from: 26