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Case 1

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, SaO 2 97. CXR NAD

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Case 1

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  1. 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

  2. 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 Case 1

  3. DDX • PE, pneumothorax, pneumonia, Most likely – PE

  4. 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.

  5. 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

  6. 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.

  7. Image – describe this CXR

  8. 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 Case 2 questions

  9. 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.

  10. 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?

  11. 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) History – sounds like asthma

  12. 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

  13. Investigations • Bed side • PEFR • counting test • CXR only if suspect: • pneumothorax • pneumonia • severe disease • ABG • if Sat<92% on RA

  14. Management options • Airway • oxygen • BIPAP/CPAP • bronchodilators • B agonists • anticholinergics • aminophylline • magnesium • ketamine

  15. Management options • steroids • What would you use in this case?

  16. 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?

  17. 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

  18. B agonists • intravenous • side effects • tachycardia • tremor • hypokalaemia • hyperglucaemia • lactic acidosis

  19. 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

  20. Case 4 • CXR NAD • ECG sinus tachycardia, RBBB, ST depression V1, V2

  21. 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

  22. 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 4

  23. 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.

  24. Case 5 questions • What are the appropriate initial investigations • What are the likely causes for his pulmonary oedema • What are the appropriate emergency treatments

  25. 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?

  26. Further history treatment at home? Normal treatment? Past history asthma indicators of severity PEFR (normal PEFR) Who manages the asthma? Any asthma education? Case 6; Moderate asthma

  27. 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?

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

  29. 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?

  30. 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

  31. Examination accessory muscle use cyanosis hypoxia precipitating factors infection bronchospasm LVF/IHD sputum retention what investigations?

  32. 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

  33. Severe asthma not responding • intravenous B agonists • BIPAP/CPAP • ?theophylline • Intubation • Ketamine induction agent of choice • bronchodilator • doesn’t reduce respiratory drive

  34. 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?

  35. 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?

  36. 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

  37. 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?

  38. 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?” COAD admit or discharge?

  39. 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

  40. Case 9 • CXR LUL consolidation • ECG sinus tachycardia • ABG pH 7.35 O2 70 CO2 45 HCO3 22

  41. 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 9

  42. 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

  43. 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

  44. Image gallery – describe and give likely diagnosis

  45. Diagnosis?

  46. Diagnosis

  47. Diagnosis

  48. Describe this CXR

  49. Emergency Department HMO education series 2012

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