5 Case 1 59 yo female CC: HPI PMHx left upper chest pain shortness of breathHPISudden onset while watching televisionIncreased pain with inspirationNon productive coughNo fevers or chillsTried acetaminophen without reliefPMHxHypertensionhypercholesterolemia
6 Case 1 Surgical Hx Social Hx Family Hx 2 wks s/p partial colectomy for diverticulitisSocial HxNo tobacco, EtOH or drug useMarriedWorks in the food industriesFamily Hxhypertension
8 Pulmonary Embolism Occurs a lot more than we think it does! 1.5 million DVT30% symptomatic PE, 30% asymptomatic PE50k deaths/year2.5% mortality if dx’d30% mortality if not dx’dHigh index of suspicion1.5 million DVTs per year. 30% of those go onto symptomatic PE, 30% asymptomatic, the other 40% no PE sequelaeDx’d = diagnosed
9 Symptoms of Acute Pulmonary Embolism Massive EmboliSubmassive Emboli(n=197)(n=130)Chest Pain85%82%Pleuritic64%Non Pleuritic6%8%DyspneaApprehension65%50%Cough53%52%Hemoptysis23%40%Sweats29%Syncope20%4%Classic findings are not so sensitive…
11 Signs of Acute Pulmonary Embolism Massive PESubmassive PERR > 16/min95%87%Rales57%60%Increased S258%45%HR >100/min48%38%Temp > 37.843%42%Phlebitis36%26%Gallop39%25%Diaphoresis27%Edema23%Murmur16%Cyanosis9%97% one of the following: Chest pain, RR > 20, Dyspnea
12 Pulmonary Embolism ECG findings S1Q3T3 Tachycardia 25 % of the time RV strainTachycardiaMost common
13 When to test?!? Everyone? High risk only? Who is safe to clinically rule out PE?
14 PERC/Well’s Criteria Clinical rules to limit testing Low risk pts have false positive rates and morbidity/mortality with treatmentDirects when to work-up
15 Wells et al. Ann Int Med 2001; 135:98-107 Pulmonary EmbolusWells Criteria – What is the pre-test probability?3.0 Signs/Symptoms of DVT1.5 HR>1001.5 Immobilization >3d or surgery in past 4 wks.1.5 Prior DVT or PE1.0 Hemoptysis1.0 Malignancy2.0 PE as likely or more likely than alternative diagnosisHigh Probability > 6.0Moderate Probability 2.0 – 6.0Low Probability < 2.0Wells et al. Ann Int Med 2001; 135:98-107
16 PERC Rule Age <50 HR <100 RA SpO2 >94% No prior PE/DVT No recent surgeryNo estrogenNo DVT findingsNo hemoptysisWill have a PTP <2% and therefore will not benefit from an evaluation for PEKline JA et al. J. Thrombosis Haemostasis 2004; 2:
24 Konstantinides et al NEJM 2002;347(15):1143-1150 Pulmonary EmbolismTreatmentHigh suspicion prior to imaging = heparinProven with imaging = heparin (LMW or UFH)Thrombolytics in select casesPerimortemRV dysfunction on echoPulmonary HTN on echoPulmonary HTN on R heart cathNew ECG signs of RV strainKonstantinides et al NEJM 2002;347(15):
25 Case 1 Summary Risk: age, post-op Pleuritic chest pain Mild tachypnea but vital signs otherwise normal = don’t be fooled!High index of suspicion!
26 Case 2 85 yo male CC: Cough, fever HPI: 3 days of progressive cough with green sputum production.Fevers and chillsPleuritic R sided chest painPMHx: CAD, HTN, hypercholesterolemia
27 Case 2 Surg Hx: TURP, Coronary stent x 2, appy Soc Hx: remote tobacco, occasional EtOH, no drug use. Widowed. Retired fisherman.FHx: Coronary diseaseROS: no HA, abdominal pain, N/V/D, urinary symptoms
28 Case 2 Vitals: T 38.5 HR 95 RR 20 BP 105/62 SpO2 94% room air Physical:HEENT: dry mucous membranesCor: RRR no murmursLungs: LLL crackles & occ wheezeAbd: soft NT/NDAssessment?? Plan?
29 Pneumonia #1 infectious mortality #6 overall1% as outpt, 25% when needing admission#1 cause nosocomial infectious mortalityUp to 50% mortality25-50% of all ICU pts get pneumonia
30 Pathogens Typical S pneumoniae, H Flu, Staphylococcus AtypicalLegionella, Mycoplasma, ChlamydiaEtohKlebsiella pneumoniaeDM/DKAS pneumoniae/S aureusHIVbased on CD4 countCOPDHaemophilus influenzae/Moraxella catarrhalisSickle CellS pneumoniae/H influenzae
32 Treatment Ceftriaxone + Macrolide or Fluroquinolone (moxi/levo) Typical and Atypical coverageMay to Cefepime for better G-Hospital/Nursing HomeHealth care associated (includes dialysis pts)Add VancoAdmit or outpt therapy?
42 Case 3 24 yo female CC: Shortness of breath, wheezing HPI: 2 days of gradual increased shortness of breathWorse today without relief with albuterol MDINon productive coughNo feversRecently got a new kitten
43 Case 3 PMHx: asthma All/Meds: none/albuterol MDI Surgical Hx: none No prior hospitalizationsAll/Meds: none/albuterol MDISurgical Hx: noneSocial Hx: ½ ppd tobacco, no EtOH or drugs. Single. WaitressFHx: COPDROS: negative
44 Case 3 Vitals: T 37.8 HR 105 RR 22 BP 140/90 SpO2 91% RA Exam: +accessory muscle use, decreased air movement and very little wheezingAssessment?? Plan?
46 Physical Exam Tachypnea Tachycardia Cough Prolonged expiratory phase WheezingNOT an accurate indicator of the severity of an attackBEWARE of the silent chest!!!Wheezing may be ABSENT or only barely audible in patients with severe obstruction
47 Physical Examination Severe obstruction: Inability to speak Use of accessory musclesAltered mental statusDiaphoresisThe ‘silent chest’
48 Can we accurately risk stratify asthma patients with our exam alone? No… clinicians & patients are notoriouslyinaccurate when assessing severity.Checking an objective measure oflung function is considered the standard.
50 Peak Expiratory Flow Rates Should be measured before and after each treatmentEasiest test to perform in the ED
51 Peak Expiratory Flow Rates Provides an objective measureBased on height, age, genderIs effort-dependentUseful to assess the response to Rx<25% Severe25%-50% Moderate50%-70% Mild>70% Discharge Goal
52 Pulse Oximetry Used to assess and follow oxygenation O2 sats < 90% indicate a severe asthma attack and significant hypoxemiaMay have near-normal pulse-ox with impending hypercapneic respiratory failure
53 Arterial Blood Gases Respiratory alkalosis typical Inaccurate predictor of outcomeWill seldom alter your treatment planPainful and not free
54 Chest Radiography Adds little to decision making in most patients The presence of ‘abnormal’ findings on CXR seldom alters managementShould not be ordered routinely
55 Indications for CXR First episode of wheezing Unclear diagnosis Patients refractory to therapyRespiratory failureClinical evidence of infection, pneumothorax, or pneumomediastinum
56 Complete Blood CountOften elevated from stress of acute asthma attack or chronic steroid useMild eosinophilia is commonNOT routinely orderedIndications: infectious work-up
58 Beta Agonists Mainstay of acute therapy Promote bronchodilation by increasing cAMPPrimary effect is small airwaysOnset of action < 5 min
59 β-Agonists: MDI vs. Nebulizer? Both are equally effective, even in severe asthmaMDI is substantially cheaper6 puffs = 2.5 mg via a holding chamber nebulizer
60 Anticholinergic Agents Produce bronchodilation by inhibition of vagally-mediated bronchoconstrictionDecrease cGMPPrimarily affect large, central airwaysOnset of action up to 30 min and peak in 1-2 hrsUse in combination with beta-agonists as first-line therapy
61 Steroids Administer early Used to treat the inflammatory component of asthmaReduce the rate of relapse and the rate of hospital admission
62 Oral Versus IV? Both routes equally effective Oral route preferred Methylprednisolone mg IVPrednisone 1-2mg/kg POOral route preferredEasier and fasterDecreases pain/anxiety of IVCheaperIndications for IV steroids:Severe asthma attack, ie dyspnea, use of accessory musclesNausea/vomiting
63 Inhaled SteroidsIn chronic asthma the regular use of inhaled steroids has been shown to:Suppress airway inflammationDecrease beta-agonists useDecrease the frequency of acute exacerbationsDecrease mortality related to acute asthma
64 Evidence Supporting the Role of Inhaled Corticosteroids In Controlling AsthmaThe emergency physician can use the “rule of two” to determine if a patient’s asthma is well controlled:Use of a rescue inhaler >2 times a weekAwakening with an asthma attack > 2 times a monthUse of >2 quick-relief β-agonist canisters/yearSinger A. Acad Emerg Med 2005; 45:
65 Inhaled Steroids After Discharge? Use BIDAlways use a spacerRinse mouth after use to reduce complications (dysphonia, S/T, oropharyngeal candidiasis)
66 Case 4 69 yo male CC: difficulty breathing HPI Recent cold symptoms x 4 daysNow with cough, increased shortness of breathPoor exercise toleranceCough is productive with yellow sputumNo fevers, N/V/D, or other complaints
67 Case 4 PMHx: HTN, COPD, hypercholesterolemia All: PCN Meds: combivent, lipitor, HCTZSurgical Hx: cholecystectomySocial Hx: 70 pk-yr tobacco, +EtOH, no drug use; married, retired ship builderFHx: emphysemaROS: negative
68 Case 4 Vitals: T 37.6 HR 100 RR 20 BP 150/94 SpO2 89% room air Physical: pursed-lip breathing, barrel chest, using accessory muscles. Distant heart and lung sounds, occasional wheeze. +clubbingAssessment?? Plan?
69 COPDDefinitionChronic bronchitis: Chronic, productive cough x 3 months in each of 2 successive years in which other causes of chronic cough have been eliminated (Blue bloaters)Emphysema: abnormal permanent enlargement of the air spaces distal to the terminal bronchioles, accompanied by destruction of bronchiolar walls but without obvious fibrosis (Pink puffers)
70 COPD Exacerbations Worsening airflow obstruction due to Bronchospasm Sputum production (infectious, environmental irritants)Cardiovascular deterioration
72 COPD Work-up CBC (r/o anemia) CXR (r/o infection, ptx, CHF) ECG Other labsLytesCardiac enzymesBNPTheophylline level (if on med, uncommon these days)
73 COPD Treatment Oxygen Bronchodilation Decrease mucous production Most have baseline sats of 88-91% with mod/severe diseaseHypoxic driveBronchodilationBeta-agonists i.e. albuterolDecrease mucous productionAnticholinergic i.e. atroventDecrease inflammationSteroid therapyTreat infection or underlying causeSimilar to asthma treatmentCombivent or Duoneb
74 Summary Dyspnea = Subjective Large differential to consider… Pulmonary EmbolusPneumoniaAsthmaCOPDAMI, CHF, Anemia, Tox, pneumothorax, airway obstruction etc.Discussed more of the common complaints