2Pulmonary Diseases & Disorders Pulmonary Disease & Conditions may result from:Infectious causesNon-Infectious causesAdversely affect one or more of the followingVentilationDiffusionPerfusion
3Pulmonary Diseases & Disorders The Respiratory Emergency may stem from dysfunction or disease of (examples only):Control SystemHyperventilationCentral Respiratory DepressionCVAThoracic BellowsChest/Diaphragm TraumaPickwickian SyndromeGuillian-Barre SyndromeMyasthenia GravisCOPD
4Pulmonary Diseases & Disorders The Respiratory Emergency may affect the upper or lower airwaysUpper Airway ObstructionTongueForeign Body AspirationAngioneurotic EdemaMaxillofacial, Larnygotracheal TraumaCroupEpiglottitis
6Pulmonary Diseases & Disorders The Respiratory Emergency may stem from Gas Exchange Surface AbnormalitiesCardiogenic Pulmonary EdemaNon-cardiogenic Pulmonary EdemaPneumoniaToxic Gas InhalationPulmonary EmbolismDrowning
7Pulmonary Diseases & Disorders Problems with the GasExchange Surface
9Pulmonary Edema: Pathophysiology A pathophysiologic condition, not a diseaseFluid in and around alveoliInterferes with gas exchangeIncreases work of breathingTwo TypesCardiogenic (high pressure)Non-Cardiogenic (high permeability)
10Pulmonary Edema High Pressure (cardiogenic) AMIChronic HTNMyocarditisHigh Permeability (non-cardiogenic)Poor perfusion, Shock, HypoxemiaHigh Altitude, DrowningInhalation of pulmonary irritants
11Cardiogenic Pulmonary Edema: Etiology Left ventricular failureValvular heart diseaseStenosisInsufficiencyHypertensive crisis (high afterload)Volume overloadIncreased Pressure in Pulmonary Vascular Bed
12Pulmonary Edema High Permeability Disrupted alveolar-capillary membraneMembrane allows fluid to leak into the interstitial spaceWidened interstitial space impairs diffusion
15Management of Non-Cardiogenic Pulmonary Edema PositionOxygenPPV / IntubationCPAPPEEPIV Access; Minimal fluid administrationTreat the underlying causeDiuretics usually not helpful; May be harmfulTransport
18Pneumonia Fifth leading cause of death in US/Canada Group of Specific infectionsRisk factorsCigarette smokingExposure to coldExtremes of ageyoungold
19Pneumonia Inflammation of the bronchioles and alveoli Products of inflammation (secretions, pus) add to respiration difficultyGas exchange is impairedWork of breathing increasesMay lead toAtelectasisSepsisVQ MismatchHypoxemia
21Presentation of Pneumonia Shortness of breath, DyspneaFever, chillsPleuritic Chest Pain, TachycardiaCoughGreen/brown sputumMay have crackles, rhonchi or wheezing in peripheral lung fieldsConsolidationEgophony
22Management of Pneumonia Treatment mostly based upon symptomsOxygenRarely is intubation requiredIV Access & RehydrationB2 agonists may be usefulAntibiotics (e.g. Rocephin)Antipyretics
23Pneumonia: Management MD follow-up for labs, cultures & RxTransport considerationsElderly have significant co-morbidityYoung have difficulty with oral medicationsED vs PMD office/clinicTransport in position of comfortWould an anticholinergic like Atrovent be useful in managing pneumonia?
25Pulmonary Embolism ~ 50,000 deaths / year/ US ~5% of all sudden deaths <10% of all PE result in death
26Pulmonary Embolism: Pathophysiology Something moving with flow of blood passes through right heart into pulmonary circulationIt reaches an area too narrow to pass through and lodges therePart of pulmonary circulation is blockedBlood:Does not pass alveoliDoes not exchange gases
27Pulmonary Embolism (PE) A disorder of perfusionCombination of factors increase probability of occurrenceHypercoagulabilityPlatelet aggregationDeep vein stasisEmbolus usually originates in lower extremities or pelvis
28Pulmonary Embolism (PE) Risk factorsVenostasis or DVTRecent surgery or traumaLong bone fractures (lower)Oral contraceptivesPregnancySmokingCancer
29Pulmonary Embolism: Etiology Most Common Cause = Blood ClotsVessel Wall InjuryVirchow’sTriadHypercoagulabilityVenous Stasis
30Pulmonary Embolism: Etiology Other causesAirAmniotic fluidFat particles (long bone fracture)Particulates from substance abuseVenous catheter
31Pulmonary Embolism: Signs & Symptoms Small EmboliRapid OnsetDyspneaTachycardiaTachypneaFeverEpisodic = ShowersEvidence or history of thrombophlebitisConsider early when no other cardiorespiratory diagnosis fits
33Pulmonary Embolism: Signs & Symptoms Very Large EmboliPreceded by S/S of Small & Larger Emboli plus:Central chest painDistended neck veinsAcute right heart failureShockCardiac arrest
34There are NO assessment findings specific to pulmonary embolism Pulmonary Embolism: Signs & SymptomsThere are NO assessment findings specific to pulmonary embolism
35Pulmonary Embolism: Management Management based on severity of Sx/SxAirway & BreathingHigh concentration O2Consider assisting ventilationsEarly IntubationCirculationIV, 2 lg bore sitesFluid bolus then TKO; Titrate to BP ~ 90 mm HgMonitor ECGRapid transport
36PE Management Thrombolytics Rapid transport to appropriate facility Aspirin & Heparin (questionable if any benefit)Rapid transport to appropriate facilityEmbolectomy or thrombolytics at hospital (rarely effective in severe cases due to time delay)Poor prognosis when cardiac arrest follows
37But the next one they throw might! Pulmonary EmbolismIf the patient is alive when you get to them, that embolus isn’t going to kill them.But the next one they throw might!
38Pleurisy Inflammation of pleura caused by a friction rub layers of pleura rubbing togetherCommonly associated with other respiratory disease
39Presentation of Pleurisy Sharp, sudden and intermittent chest pain with related dyspneaPossibly referred to shoulderMay or with respirationPleural “friction rub” may be audible”May have effusion or be dry
40Pleurisy Management Based upon severity of presentation Mostly supportive
41Pulmonary Diseases & Disorders Problems with Airway Obstructions
44Obstructive Airway Diseases Asthma experienced by ~ % of Canadian populationMortality rate increasingFactors leading to Obstructive Airway DiseasesSmokingExposure to environmental agentsGenetic predispositionHow does this differ from “COPD”?
45Obstructive Airway Disease Exacerbation FactorsIntrinsicStress (especially in adults)URIExerciseExtrinsicCigarette SmokeAllergensDrugsOccupational hazards
46Obstructive Airway Disease General PathophysiologySpecific pathophysiology varies by diseaseObstruction in bronchiolesSmooth muscle spasm (beta)Mucous accumulationInflammationObstruction may be reversible or irreversible
47Obstructive Airway Disease General PathophysiologyObstruction results in air trappingBronchioles usually dilate on inspirationDilation allows air to enter even in presence of “obstruction”Bronchioles tend to constrict on expirationAir becomes trapped distal to obstruction
52Emphysema: Definition Destruction of alveolar wallsDistention of pulmonary air spacesLoss of elastic recoilDestruction of gas exchange surface
53Emphysema: Incidence Male > females Urban area > rural areas Age usually > 55
54Emphysema:Etiology Smoking Environmental factors 90% of all casesSmokers 10x more likely to die of COPD than non-smokersEnvironmental factorsAlpha – 1 antitrypsin deficiencyhereditary50,000 to 100,000 casesmostly people of northern European descent
55Emphysema: Pathophysiology Decreased surface area leads to decreased gas exchange with bloodLoss of pulmonary capillaries & hypercapnia lead toincreased resistance to blood flow which leads topulmonary HTNright heart failure (cor pulmonale)
56Emphysema: Pathophysiology Loss of elastic recoil leads to increased residual volume and CO2 retentionAir TrappingHyperinflationHypercapnia -> pulmonary vasoconstriction -> V/Q mismatch
57Emphysema: Signs and Symptoms Increasing dyspnea on exertionNon-productive coughMalaiseAnorexia, Loss of weightHypertrophied respiratory accessory muscles
58Emphysema: Signs and Symptoms Increased Thoracic AP Diameter (Barrel Chest)Decreased lung/heart soundsHyperresonant chest
59Emphysema: Signs and Symptoms Lip pursing on exhalationClubbed fingertipsAltered blood gasesNormal or decreased PaO2Elevated CO2Cyanosis occurs LATE in course of diseasePINK PUFFER
65Chronic Bronchitis: Pathophysiology Hypoxemia leads toincreased RBC’s w/o oxygen which leads tocyanosisHypercarbia leads topulmonary vascular constriction which leads toincreased right ventricular work which leads toright heart failure which may progress tocor pulmonale
66Chronic Bronchitis: Signs and Symptoms Increasing dyspnea on exertionFrequent colds of increasing durationProductive coughWeight gain, edema (right heart failure)Rales, rhonchi, wheezingBluish-red skin color (polycythemia)Headache, drowsiness (increased CO2)
67Chronic Bronchitis: Signs and Symptoms Decreased intellectual abilityPersonality changesAbnormal blood gasesHypercarbiaHypoxiaCyanosis EARLY in course of diseaseBLUE BLOATER
68COPD Assessment Findings Chronic condition acute episodeS&S of work of breathing and/or hypoxemiaUse of accessory musclesIncreased expiratory effortTachycardia, AMS, CyanosisWheezing, Rhonchi, LSThin, red/pink appearanceSaturation usually normal in emphysema
69COPD: Management Causes of Decompensation Respiratory infection (increased mucus production)Chest trauma (pain discourages coughing or deep breathing)Sedation (depression of respirations and coughing)Spontaneous pneumothoraxDehydration (causes mucus to dry out)
70TRUE HYPOXIC DRIVE IS VERY RARE COPD: ManagementAirway and BreathingSitting position or position of comfortCalm & ReassureEncourage coughAvoid exertionOxygenDon’t withholdMaintain O2 saturation above 90 %TRUE HYPOXIC DRIVE IS VERY RARE
71COPD: Management Ventilation Circulation Avoid intubation unless absolutely necessarynear respiratory failureexhaustionCirculationIV TKOTitrate fluid to degree of dehydration250 cc trial bolusExcessive fluid may precipitate CHFMonitor ECG
72COPD: Management Drug Therapy Obtain thorough medication history Nebulized Beta 2 agonistsAlbuterolTerbutalineMetaproterenolIsoetharine
73REMEMBER All bronchodilators are potentially arrhythmogenic COPD: ManagementREMEMBERAll bronchodilators are potentially arrhythmogenic
74COPD: Management Drug Therapy Ipratropium (anticholinergic) by SVN (beta-2 agonist) by MDI, SQ or IVCorticosteroids (anti-inflammatory agent) by IV
75COPD: Management Avoid Sedatives Restlessness = hypoxia Antihistamines Dry secretions, decrease LOCEpinephrineMyocardial ischemia, arrhythmiasIntubationdifficult to wean off ventilator
77Asthma: DefinitionLower airway hyper-responsiveness to a variety of stimuliDiffuse reversible airway obstruction or narrowingAirway inflammation
78Asthma: Incidence 50% onset before age 10 33% before age 30 “Asthma” in older patients suggests other obstructive pulmonary diseasesRisk FactorsFamily history of asthmaPerinatal exposure to airborne allergens and irritantsGenetic hypersensitivity to environmental allergens (Atopy)
79Asthma Diagnosis H&P, Spirometry Hx or presence of episodic symptoms of airflow obstructionairflow obstruction is at least partially reversiblealternative diagnoses are excluded
80Asthma Commonly misdiagnosed in children as Chronic bronchitis Recurrent croupRecurrent URIRecurrent pneumonia
81Asthma Often triggered by: Exacerbation Cold temperature Respiratory InfectionsVigorous exerciseEmotional StressEnvironmental allergens or irritantsExacerbationExtrinsic common in childrenIntrinsic common in adults
85Asthma: Pathophysiology Cast of airway produced by asthmatic mucus plugs
86Asthma: Pathophysiology Difficulty exhalingchest hyperinflationPoor gas exchangehypoxiahypercarbiaIncreased respiratory water lossdehydration
87Asthma: Types Type 1 Extrinsic Classic allergic asthma Common in children, young adultsSeasonal in natureSudden brief attacksMajor component is bronchospasmGood bronchodilator response
88Asthma: Types Type 2 Extrinsic Asthma Adults < 35 Long term exposure to irritantsMore inflammation than Type 1 ExtrinsicDoes not respond well to bronchodilatorsNeeds treatment with corticosteroids
89Asthma: Types Intrinsic Asthma Adult > 35 No immunologic cause Aspirin sensitivity/nasal polypsPoor bronchodilator response
90Asthma: Signs and Symptoms Onset of attacks associated with “triggers”DyspneaNon-productive coughTachypneaExpiratory wheezingAccessory muscle useRetractions
91Asthma: Signs and Symptoms Absence of wheezingIMPENDING RESPIRATORY ARREST!
92Asthma: Signs and Symptoms TachycardiaPulsus paradoxus in severe attacksAnxiety, restlessness (hypoxia) progressing to drowsiness, confusion (hypercarbia)
93Asthma: Signs and Symptoms Lethargy, confusion, suprasternal retractions RESPIRATORY FAILURE
94Asthma: Signs and Symptoms Early Blood Gas ChangesDecreased PaO2Decreased PaCO2WHY?
95Asthma: Signs and Symptoms Later Blood GasesDecreased PaO2Normal PaCO2IMPENDING RESPIRATORY FAILURE
96Asthma: Signs and Symptoms Still Later Blood GasesDecreased PaO2Increased PaCO2RESPIRATORY FAILURE
97Asthma: Risk Assessment Prior ICU admissionsPrior intubation>3 ED visits in past year>2 hospital admissions in past year>1 bronchodilator canister used in past monthUse of bronchodilators > every 4 hoursChronic use of steroidsProgressive symptoms in spite of aggressive Rx
98Asthma: Management Airway Breathing Sitting position or position of comfortHumidified O2 by NRB maskDry O2 dries mucus, worsens plugsEncourage coughingConsider intubation, assisted ventilationImpending respiratory failureAvoid if at all possible
99Asthma: Management Circulation IV TKO Assess for dehydration Titrate fluid administration to severity of dehydrationTrial bolus of 250 ccMonitor ECG, Pulse Oximetry
100Asthma: Management Obtain medication history Consider Overdose Dysrhythmias
103POSSIBLE BENEFIT IN PATIENTS WITH VENTILATORY FAILURE Asthma: ManagementSubcutaneous beta agentsEpinephrine 1:1000 q 30 minutes up to 3 dosesAdult – 0.3 mg SQ/IMPediatric – 0.1 to 0.3 mg SQ/IMPOSSIBLE BENEFIT IN PATIENTS WITH VENTILATORY FAILURE
104Asthma: ManagementUse EXTREME caution in giving two sympathomimetics or two doses to same patientMonitor ECG
106Asthma: Management Continuous Monitoring & Frequent Reassessment Need for transport? Destination?
107Asthma: Management Transport Considerations How severe is the episode? Is the patient improving?How extensive (invasive) were the required therapies?What does he/she normally do after treatment?Medical Control or PMD consult
108Drug Delivery Methods: Review MDI vs. MDI w/ spacer vs. SVN vs. SQ injection
109Asthma unresponsive to beta-2 adrenergic agents Status AsthmaticusAsthma unresponsive to beta-2 adrenergic agents
110Status Asthmaticus Oxygen (humidified if possible) Nebulized beta-2 agentsNebulized IpratropiumCorticosteroidsIV or SQ terbutaline or epinephrineAminophylline (controversial)Magnesium sulfate (controversial)IntubationCaution with PPV
111ALL THAT WHEEZES IS NOT ASTHMA Golden RuleALL THAT WHEEZES IS NOT ASTHMAPulmonary edemaPulmonary embolismAllergic reactionsCOPDPneumoniaForeign body aspirationCystic fibrosis
118Hyperventilation Syndrome Brady Textbook Correction, Vol. 3, p. 57Table 1-4: These are NOT Causes of hyperventilation syndromeA diagnosis of EXCLUSION!!!An increased ventilatory rate thatDOES NOT have a pathologic originResults from anxietyRemains a real problem for the patient
119Hyperventilation Syndrome: Pathophysiology Tachypnea or hyperpnea secondary to anxietyDecreased PaCO2Respiratory alkalosisVasoconstrictionHypocalcemiaDecreased O2 Release to Tissues
121Hyperventilation Syndrome: Signs & Symptoms Rapid breathingCool & possibly pale skinCarpopedal spasmDysrhythmiasSinus TachycardiaSVTSinus arrhythmiaLoss of consciousness and seizures (late & rare)
122Hyperventilation Syndrome: Management Educate patient & familyConsider possible psychopathology especially in “repeat customers”Transport occasionally requiredIf loss of consciousness, carpopedal spasm, muscle twitching, or seizures occur:Monitor EKGIV TKOTransport
123Hyperventilation Syndrome Serious diseases can mimic hyperventilationHyperventilation itself can be serious
125Laryngotracheobronchitis (Croup) Common syndrome of infectious upper airway obstructionViral infectionparainfluenza virusSubglottic Edemalarynx, trachea, mainstem bronchiUsually 3 months to 4 years of age
126Croup: Signs & Symptoms Gradual onset (several days)Often begins with Sx of URIMay begin with only low grade feverHoarsenessCough“Seal Bark Cough”“Brassy Cough”Nocturnal episodes of increased dyspnea and stridor
127Croup: Signs & Symptoms Evidence of respiratory distressTracheal tuggingSubsternal/intercostal retractionsAccessory muscle useInspiratory stridor or respiratory distress may develop slowly or acutely
128Croup: Management Usually requires little out of home treatment Calm & Prevent agitation!!!Moist cool air - mistHumidified O2 by mask or blowbyDo Not Examine Upper Airways!!!
129Croup: Management If in respiratory distress: Racemic epinephrine via nebulizerDecreases subglottic edema (temporarily)Necessitates transport for observation for reboundIV TKO - ONLY if severe respiratory distressTransport
130Epiglottitis Bacterial infection (Hemophilus influenza ) Edema of epiglottis (supraglottic)partial upper airway obstructionTypically affects 3-7 year olds
131Epiglottitis: Presentation Age: 3-7 years of agecan occur in adultscan occur in infantsRapid onset & progressionFeverSevere sore throatDysphagiaMuffled voiceDrooling
132Epiglottitis: Presentation Respiratory difficultyStridorUsually in an upright, sitting, tripod positionChild may go to bed asymptomatic and awaken during the night withsore throatpainful swallowingrespiratory difficulty
133Epiglottitis: Management Immediate life threat (8-12% die from airway obstruction)Do NOT attempt to visualize airwayAllow child to assume position of comfortAVOID agitation of the child!!!AVOID anxiety of the healthcare providers!!!O2 by high concentration mask
134Epiglottitis: Management If respiratory failure is eminent:IV TKO ONLY if eminent or respiratory arrestBe prepared to take control of airwayIntubation equipment with smaller sized tubesNeedle cricothyrotomy & jet ventilation equipmentRapid but calm transportAppropriate facility
135Upper Respiratory Infection Common illnessRarely life-threateningOften exacerbates underlying pulmonary conditionsMay become more significant in some patientsImmunosuppressedElderlyChronic pulmonary disease
136Upper Respiratory Infection PreventionAvoidance is nearly impossibleToo many potential causesTemporarily impaired immune systemBest prevention strategy is handwashingCovering of mouth during sneezing and coughing also helpful
137Pathophysiology of URI Wide variety of bacteria and viruses are causesNormal immune system response results in presentation20-30% are Group A streptococciMost are self-limiting diseases
138Presentation of URI Symptoms Signs Sore throat Fever Chills HA Cervical adenopathyErythematous pharynxPositive throat culture (bacterial)
139Management of URI Usually requires no intervention Oxygen if underlying condition has been exacerbatedRarely, pharmacologic interventions are requiredBronchodilatorsCorticosteroidOccasionally, transport requiredKey question: Destination?
141Respiratory Depression: Causes Head traumaCVADepressant drug toxicityNarcoticsBarbituratesBenzodiazepinesETOH
142Respiratory Depression: Recognition Decreased respiratory rate (< 12/min)Decreased tidal volumeDecreased LOCUse Your StethoscopeLook, Listen, FeelTHEY PROBABLY AREN’TIf you can’t tell whether a patient is breathing adequately...
143Respiratory Depression: Management AirwayOpen, clear, maintainConsider endotracheal intubationThe need to VENTILATE is not the same as the need to INTUBATE
144Respiratory Depression: Management BreathingOxygenate, ventilateRestore normal rate, tidal volumeOxygen alone is INSUFFICIENT if Ventilation is INADEQUATE
145Respiratory Depression: Management CirculationObtain vascular accessMonitor EKG (Silent MI may present as CVA)Manage CauseCheck Blood SugarConsider Narcan 2mg IV push if S/S suggest narcotic overdoseIntubate if can not find or treat cause
146Guillian-Barre´ Syndrome Autoimmune diseaseLeads to inflammation and degeneration of sensory and motor nerve roots (de-myelination)Progressive ascending paralysisProgressive tingling and weaknessMoves from extremities then proximallyMay lead to respiratory paralysis (25%)
147Guillian-Barre´ Syndrome Management Treatment based on severity of symptomsControl airwaySupport ventilationOxygenTransport in cases of respiratory depression, distress or arrest
148Myasthenia Gravis Autoimmune disease Causes loss of ACh receptors at neuromuscular junctionAttacks the ACh transport mechanism at the NMJEpisodes of extreme skeletal muscle weaknessCan cause loss of control of airway, respiratory paralysis
149Myasthenia Gravis Presentation Gradual onset of muscle weaknessFace and throatExtreme muscle weaknessRespiratory weakness -> paralysisInability to process mucus
150Myasthenia Gravis Management Treat symptomaticallyWatch for aspirationMay require assisted ventilationsAssess for Pulmonary infectionTransport based upon severity of presentation
152What would you like to include in your initial differential diagnosis? Case OneIt is 1430 hrs. You are called to a business for a “possible stroke.” The patient is a 20-year-old female complaining of dizziness and of numbness around her mouth and fingertips.What would you like to include in your initial differential diagnosis?
153What therapies, if any, would you like to begin? Case OneInitial AssessmentAirway: Open, maintained by patientBreathing: Rapid, deep, regular; no accessory muscle use or retractionsCirculation: Radial pulses present, rapid, full; Skin warm, dry; capillary refill < 2 secondsDisability: Awake, alert, anxiousWhat therapies, if any, would you like to begin?
154Would you like to make any Changes to your therapies or Diff Dx? Case OneVital SignsP: 126 strong, regularR: 26 deep, regularBP: 130/82Physical ExamChest: BS present, equal bilaterally; no adventitious soundsExtremities: Equal movement in all extremities; no weakness; hands coolOxygen saturation: 98%Would you like to make any Changes to your therapies or Diff Dx?
155Case One History Allergies: NKA Medications: Birth control pills Past History: No significant past history; no history of smokingLast Meal: Lunch 2 hours agoEvents: S/S began suddenly after argument with supervisor
156Case One What problem do you now suspect? How would you manage this patient?
157What would you like to include in your differential diagnosis? Case TwoIt is 0530 hours. You are called to a residence to see a child with “a very high fever and difficulty breathing.” The patient is a 6-old-female. Mother says the child woke up crying about 2 hours ago.What would you like to include in your differential diagnosis?
158What therapies, if any, would you like to begin now? Case TwoInitial AssessmentAirway: Inspiratory stridor audibleBreathing: Rapid, shallow, laboredCirculation: Radial pulses present, rapid, weak; skin pale, hot, diaphoretic; capillary refill is 2 secondsDisability: Awake, alert, obviously frightened and in acute distressWhat therapies, if any, would you like to begin now?
159Would you like to make any Changes to your therapies or Diff Dx? Case TwoVital SignsP: 130 weak, regularR: 32 shallow, regular with stridorBP: 110/70Physical ExamHEENT: Flaring of nostrils; accessory muscle use on inspiration; drooling presentChest: BS present, equal bilaterally; no adventitious soundsOxygen saturation: 92%Would you like to make any Changes to your therapies or Diff Dx?
160Case Two History Allergies: NKA Medications: None Past History: No significant past historyLast Meal: Dinner at about 1800 hoursEvents: Awakened with severe sore throat. Has experienced increasing difficulty breathing. Will not eat or drink. Says it hurts to swallow
161Case Two What problem do you now suspect? How would you manage this patient?
162How narrow a Differential Diagnosis can you compile at this point? Case ThreeAt 2330 hrs you are called to a residence to see a child with “difficulty breathing.” The patient is a 3 year old male.How narrow a Differential Diagnosis can you compile at this point?
163Case Three Initial Assessment Airway: Open, maintained by patient, mild stridor audibleBreathing: Rapid, shallow, laboredCirculation: Radial pulses present, weak, regular; Skin pale, warm, moist; Capillary refill <2 secondsDisability: Awake, sitting up in bed, looks tired and miserable
164Now you can narrow your Diff Dx? To what? Case ThreeVital SignsP: 100 weak, regularR: 30 shallow, labored with stridorBP: 90/50Physical ExamHEENT: Use of accessory muscles present; no droolingChest: BS present, equal bilaterally with no adventitious sounds. Auscultation difficult because of stridor and barking coughNow you can narrow your Diff Dx? To what?
165Case Three History Allergies: NKA Medication: Tylenol for fever before bedtimePast history: No significant past historyLast meal: Dinner around 1800 hoursEvents: Patient has had “cold” for about 3 days. Reasonably well during day. Awakens around midnight with high-pitched cough that sounds like a dog barking
166Case Three What problem do you suspect? How would you manage this patient?
167What is your differential diagnosis? Case FourAt 1945 hours you are dispatched to a “breathing difficulty” at Long John Silver’s. The patient is a 26-year-old female complaining of strange feeling in her mouth and difficulty swallowing.What is your differential diagnosis?
168Case Four Initial Assessment Airway: Open, maintained by patient, difficulty swallowing, voice is hoarseBreathing: Rapid, laboredCirculation: Radial pulses present, strong, regular; Skin “flushed”; Capillary refill < 2 secondsDisability: Awake, alert, very anxious
169What therapies do you want to initiate? Case FourVital SignsP: 120 strong, regularR: 26 regular, slightly laboredBP: 118/90Physical ExamHEENT: Puffiness around eyes; Lips appear swollen; Mild accessory muscle useChest: BS present, equal bilaterally; No adventitious soundsUrticaria on upper chest, extremitiesOxygen saturation: 94%What therapies do you want to initiate?
170Case FourHistoryAllergies: No drug allergies; Has experienced itching previously when eating shrimpMedications: NonePast history: No significant past history; no history of smokingLast meal: In progress at time of callEvents: Began to experience itching and difficulty swallowing after eating “fish and chips”
171Case Four What problem do you suspect? How would you manage this patient?The patient begins to have increased difficulty swallowing, increased anxiety, and increased difficulty breathing. What do you want to do now?
172Case FiveAt 0130 you are dispatched to an “unconscious person--police on location.” The patient is a 27-year-old male who is apparently unconscious. The police report they found him lying in an alleyway while they were on routine patrol. He is known to live “on the streets”.
173What therapies would you like to begin? Case FiveInitial AssessmentAirway: Controllable with manual positioningBreathing: Very slow, shallowCirculation: Radial pulses present, weak; Skin pale, cool, moist; Capillary refill 3 secondsDisability: Unconscious, unresponsive to painful stimuliWhat therapies would you like to begin?