Case StudyAn ambulance arrives to your Emergency Department with a 60-year-old woman who reports she is having difficulty breathing. Her vital signs en route were: BP 190/100, HR 118, RR 34, and SpO2 87% on RA. As they move her off of the stretcher, you notice that she’s breathing fast, she isn’t talking, and her shoulders and abdomen move with each breath. Show
Objectives
IntroductionShortness of breath is a very common cause of Emergency Department visits. In the United States, pneumonia, COPD exacerbation, heart failure exacerbation and dysrhythmias round out the top five reasons for hospital admission in patients 45 and older, after chest pain. All of those conditions, and many others, can cause shortness of breath, which makes diagnosing the root cause difficult. It is a nonspecific symptom with many possible causes and degrees of severity, making the evaluation of these patients challenging. In many cases, treatment/stabilization may actually precede establishing a final diagnosis. It is important to consider the critical diagnoses in your evaluation and look for patterns in the history and physical exam. Additional tests can be helpful in establishing a diagnosis or excluding alternative diagnoses. Initial Actions and Primary SurveyGeneral ImpressionPatients with a chief complaint of shortness of breath can vary in their degree of distress at initial presentation. Like many other complaints in the ED, the assessment begins with, “What do I see when I walk into the room?” Gaining that initial general impression within the first few seconds/minutes is critical—you may find you need to intervene to stabilize your patient before you have enough information to make a final diagnosis. Our initial general impression of this patient is that she has abnormal vital signs, is breathing rapidly and is in severe distress. We should prepare ourselves for immediate intervention. First StepsHaving additional help from nurses, medics, or other ED staff is tremendously useful. While you are assessing your patient’s ABCs, you should request the following to occur simultaneously:
If your patient fails to respond to oxygen administration and is not breathing adequately, you may need to consider more aggressive treatment with non-invasive positive pressure ventilation (NIPPV) or intubation. The patient’s first set of vital signs in the ED is consistent with those reported by EMS. She is placed on a non-rebreather mask at 15 LPM without significant improvement in her level of distress or her oxygen saturation. IV access is obtained, and patient is placed on the monitor. EKG shows sinus tachycardia. Her mental status is normal, however, and she is able to protect her airway. Respiratory therapy is paged to respond with a BiPAP machine.
History and Physical ExamIn developing a working diagnosis, the history can often provide clues to the etiology of your patient’s symptoms. If the patient is unable to answer questions because of their respiratory distress, ask the paramedics or family members if they have any useful information. They may have insight into the patient’s past medical history or pertinent events leading up to the patient’s encounter. Medications can be extremely helpful. For example, a person with an albuterol inhaler is likely to have COPD/asthma history or a person with a furosemide prescription may have a history of heart failure. Some key elements of the history:
The physical exam can also be incredibly helpful in determining a cause for your patient’s symptoms. Learning to recognize patterns that support your history can make your evaluation more efficient.
EMS reports that our patient has been out of her medications for several weeks, which include multiple antihypertensives and a diuretic. On physical examination, she has bilateral rales to the level of her shoulder blades, pitting edema in both legs, and JVD. She is placed on BiPAP, given nitroglycerin, and her symptoms and vital signs begin to improve. Diagnostic TestingAfter the initial assessment and stabilization of your patient, additional tests can be used to confirm a diagnosis or exclude other potential life-threatening diagnoses.
A bedside ultrasound is done immediately following the physical exam. Cardiac views show a severely depressed ejection fraction and lung windows show diffuse B-lines consistent with pulmonary edema. She is placed on BiPAP, given nitroglycerin, and her symptoms and vital signs begin to improve. Differential DiagnosisCritical diagnoses (and general management options) to consider in patients with respiratory distress include:
Pearls & Pitfalls
Case Study ResolutionWith continued NIPPV and nitrate therapy, our patient’s degree of respiratory distress improves significantly, and she is able to avoid intubation. She is admitted to the hospital for an acute CHF exacerbation and is restarted on her home medications. After several days of additional diuresis, she feels back to normal and is discharged home.
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