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

2. Case 1 CXR NAD ECG sinus tachycardia ABG pH 7.47 O 2 80 CO 2 35 HCO 3 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

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. Case 2 questions 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

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. History – sounds like asthma 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)

12. Examination Look 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 SaO 2 90

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

21. Case 4 ABG pH 7.35 O 2 70 CO 2 30 HCO 3 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?

22. Case 4 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 http://www.ncbi.nlm.nih. gov/pubmed/10826469

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

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 CO 2 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 CO 2  10mmHg - HCO 3  1 upto 30mmol acute CO 2  10mmHg - HCO 3  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 8 COAD management largely irreversible disease small improvements may give significant symptomatic relief manage as per asthma CO 2 retainers rare loss of hypercapnic drive low FiO 2 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. COAD admit or discharge? 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?”

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 SaO 2 90

40. Case 9 CXR LUL consolidation ECG sinus tachycardia ABG pH 7.35 O 2 70 CO 2 45 HCO 3 22

41. Case 9 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

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

48. Describe this CXR

50. Emergency Department HMO education series 2012