CLINICAL PROBLEM SOLVING WHEN YOURE ON CALL Speaker: Connie Tomada, MD

CLINICAL PROBLEM SOLVING WHEN YOURE ON CALL How to work-up and manage Shortness of Breath How to work-up and manage Shortness of Breath

CardiovascularCHF, PE PulmonaryPneumonia, asthma, COPD Others anxiety, upper airway obstruction, ascites Life-threateninghypoxia

Phone Call duration? gradual or sudden? cyanosis? reason for admission? presence of COPD or heavy smoking? (CO2 retainers) oxygen order? duration? gradual or sudden? cyanosis? reason for admission? presence of COPD or heavy smoking? (CO2 retainers) oxygen order?

Phone Call Oxygen 1 L/min O2 on NC adds 3% FiO2 on RA for CO2 retainers, start with 3-4 L/min, FiO % for asthma/COPD, aerosol treatment ABG? Oxygen 1 L/min O2 on NC adds 3% FiO2 on RA for CO2 retainers, start with 3-4 L/min, FiO % for asthma/COPD, aerosol treatment ABG?

Travel Time CardiovascularCHF, PE PulmonaryPneumonia, asthma, COPD Others anxiety, upper airway obstruction, ascites Life-threateninghypoxia

Travel Time CardiovascularCHF, PE PulmonaryPneumonia, asthma, COPD Others anxiety, upper airway obstruction, ascites Life-threateninghypoxia

Bedside rapid visual assessment (sick or critically ill?) ABG, O2, IV access & IV fluids, ECG crash cart and ECG monitor code status if considering intubation (call senior resident/ICU attending) rapid visual assessment (sick or critically ill?) ABG, O2, IV access & IV fluids, ECG crash cart and ECG monitor code status if considering intubation (call senior resident/ICU attending)

Bedside ABCs and Vital signs airway obstruction RR<12/min: narcotic OD, cushing sign paradoxical breathing fever: infection vs. PE pulsus paradoxus: asthma, COPD, cardiac tamponade ABCs and Vital signs airway obstruction RR<12/min: narcotic OD, cushing sign paradoxical breathing fever: infection vs. PE pulsus paradoxus: asthma, COPD, cardiac tamponade

Bedside Hypoxia (O2sat<92% or PaO2<60 mmHg) increase oxygen support until O2 sat >92% careful with CO2 retainer (COPD, heavy smoker), O2sat ~90% nasal cannula face mask venturi mask non- rebreather dual flow BiPap endotracheal intubation repeat ABG Hypoxia (O2sat<92% or PaO2<60 mmHg) increase oxygen support until O2 sat >92% careful with CO2 retainer (COPD, heavy smoker), O2sat ~90% nasal cannula face mask venturi mask non- rebreather dual flow BiPap endotracheal intubation repeat ABG

Bedside Hypoxia (O2sat<92% or PaO2<60 mmHg) increase oxygen support until O2 sat >92% careful with CO2 retainer (COPD, heavy smoker), O2sat ~90% nasal cannula face mask venturi mask non- rebreather dual flow BiPap endotracheal intubation repeat ABG Hypoxia (O2sat<92% or PaO2<60 mmHg) increase oxygen support until O2 sat >92% careful with CO2 retainer (COPD, heavy smoker), O2sat ~90% nasal cannula face mask venturi mask non- rebreather dual flow BiPap endotracheal intubation repeat ABG

Bedside Hypoxia (O2sat<92% or PaO2<60 mmHg) increase oxygen support until O2 sat >92% careful with CO2 retainer (COPD, heavy smoker), O2sat ~90% nasal cannula face mask venturi mask non- rebreather dual flow BiPap endotracheal intubation repeat ABG Hypoxia (O2sat<92% or PaO2<60 mmHg) increase oxygen support until O2 sat >92% careful with CO2 retainer (COPD, heavy smoker), O2sat ~90% nasal cannula face mask venturi mask non- rebreather dual flow BiPap endotracheal intubation repeat ABG

Bedside Hypoxia (O2sat<92% or PaO2<60 mmHg) increase oxygen support until O2 sat >92% careful with CO2 retainer (COPD, heavy smoker), O2sat ~90% nasal cannula face mask venturi mask non- rebreather dual flow BiPap endotracheal intubation repeat ABG Hypoxia (O2sat<92% or PaO2<60 mmHg) increase oxygen support until O2 sat >92% careful with CO2 retainer (COPD, heavy smoker), O2sat ~90% nasal cannula face mask venturi mask non- rebreather dual flow BiPap endotracheal intubation repeat ABG

Bedside Hypoxia (O2sat<92% or PaO2<60 mmHg) increase oxygen support until O2 sat >92% careful with CO2 retainer (COPD, heavy smoker), O2sat ~90% nasal cannula face mask venturi mask non- rebreather dual flow BiPap endotracheal intubation repeat ABG Hypoxia (O2sat<92% or PaO2<60 mmHg) increase oxygen support until O2 sat >92% careful with CO2 retainer (COPD, heavy smoker), O2sat ~90% nasal cannula face mask venturi mask non- rebreather dual flow BiPap endotracheal intubation repeat ABG

Bedside Hypoxia (O2sat<92% or PaO2<60 mmHg) increase oxygen support until O2 sat >92% careful with CO2 retainer (COPD, heavy smoker), O2sat ~90% nasal cannula face mask venturi mask non- rebreather dual flow BiPap endotracheal intubation repeat ABG Hypoxia (O2sat<92% or PaO2<60 mmHg) increase oxygen support until O2 sat >92% careful with CO2 retainer (COPD, heavy smoker), O2sat ~90% nasal cannula face mask venturi mask non- rebreather dual flow BiPap endotracheal intubation repeat ABG

Bedside Hypoxia (O2sat<92% or PaO2<60 mmHg) increase oxygen support until O2 sat >92% careful with CO2 retainer (COPD, heavy smoker), O2sat ~90% nasal cannula face mask venturi mask non- rebreather dual flow BiPap endotracheal intubation repeat ABG Hypoxia (O2sat<92% or PaO2<60 mmHg) increase oxygen support until O2 sat >92% careful with CO2 retainer (COPD, heavy smoker), O2sat ~90% nasal cannula face mask venturi mask non- rebreather dual flow BiPap endotracheal intubation repeat ABG

Bedside Hypoxia (O2sat<92% or PaO2<60 mmHg) increase oxygen support until O2 sat >92% careful with CO2 retainer (COPD, heavy smoker), O2sat ~90% nasal cannula face mask venturi mask non- rebreather dual flow BiPap endotracheal intubation repeat ABG Hypoxia (O2sat<92% or PaO2<60 mmHg) increase oxygen support until O2 sat >92% careful with CO2 retainer (COPD, heavy smoker), O2sat ~90% nasal cannula face mask venturi mask non- rebreather dual flow BiPap endotracheal intubation repeat ABG

Bedside Hypoxia (O2sat<92% or PaO2<60 mmHg) increase oxygen support until O2 sat >92% careful with CO2 retainer (COPD, heavy smoker), O2sat ~90% nasal cannula face mask venturi mask non- rebreather dual flow BiPap endotracheal intubation repeat ABG Hypoxia (O2sat<92% or PaO2<60 mmHg) increase oxygen support until O2 sat >92% careful with CO2 retainer (COPD, heavy smoker), O2sat ~90% nasal cannula face mask venturi mask non- rebreather dual flow BiPap endotracheal intubation repeat ABG

Intubation??? 12 30/min inability to protect airway change in MS paradoxical breathing pH<7.35 normal pH with tachypnea PaO2<60 PCO2>50 Full Code when you think its needed 12 30/min inability to protect airway change in MS paradoxical breathing pH<7.35 normal pH with tachypnea PaO2<60 PCO2>50 Full Code when you think its needed

Causes of Shortness of Breath A quick review

Acute CHF Hx of CHF or cardiac disorder, orthopnea/PND, + I/O, weight gain signs of fluid overload (JVD, insp crackles +/- pleural effusion, systolic murmurs, + HJR, edema) chest xray decrease preload: sit patient up, oxygen, furosemide, NTG, morphine look for cause of CHF Hx of CHF or cardiac disorder, orthopnea/PND, + I/O, weight gain signs of fluid overload (JVD, insp crackles +/- pleural effusion, systolic murmurs, + HJR, edema) chest xray decrease preload: sit patient up, oxygen, furosemide, NTG, morphine look for cause of CHF

Causes of CHF CAD HTN valvular heart disease cardiomyopathies pericardial disease MI Fever, infection dysrhythmia PE NSAIDS anemia CAD HTN valvular heart disease cardiomyopathies pericardial disease MI Fever, infection dysrhythmia PE NSAIDS anemia

Pulmonary Embolism Tachypnea, tachycardia and chest pain, Virchows triad (e.g. hypercoagulable state, immobility, vein injury), History of DVT Pleural rub, pleural effusion, lower extremity with edema/palpable cord/calve tenderness Stat ECG (S1Q3T3), stat CXR, stat CTA chest, echo, LE Doppler, d-dimer Heparin vs LMWH, IVC filter, thrombolysis if in shock (call senior resident) ICU transfer if with low oxygen saturation +/- intubation Tachypnea, tachycardia and chest pain, Virchows triad (e.g. hypercoagulable state, immobility, vein injury), History of DVT Pleural rub, pleural effusion, lower extremity with edema/palpable cord/calve tenderness Stat ECG (S1Q3T3), stat CXR, stat CTA chest, echo, LE Doppler, d-dimer Heparin vs LMWH, IVC filter, thrombolysis if in shock (call senior resident) ICU transfer if with low oxygen saturation +/- intubation

Pneumonia cough productive of purulent sputum, fever/chills, pleurisy, +/- immunocompromised leukocytosis, bandemia, CXR sputum GS/CS, Strep/Mycoplasma/Legionella Ag, blood culture antibiotics (refer to guidelines) cough productive of purulent sputum, fever/chills, pleurisy, +/- immunocompromised leukocytosis, bandemia, CXR sputum GS/CS, Strep/Mycoplasma/Legionella Ag, blood culture antibiotics (refer to guidelines)

Bronchospasm (Asthma/COPD) tobacco abuse, steroid use, intubation history, precipitating factors, anaphylaxis diffuse wheezing, prolonged expiration, loud P2 somnolence, pulsus paradoxus, cyanosis, accessory muscle CXR, ABG, spiromtery, pulse ox oxygen, aerosols, steroid, antibiotics tobacco abuse, steroid use, intubation history, precipitating factors, anaphylaxis diffuse wheezing, prolonged expiration, loud P2 somnolence, pulsus paradoxus, cyanosis, accessory muscle CXR, ABG, spiromtery, pulse ox oxygen, aerosols, steroid, antibiotics

Always remember... Call your senior resident if you need some assistance. Perform proper hand-offs and sign-out Call your senior resident if you need some assistance. Perform proper hand-offs and sign-out

CLINICAL PROBLEM SOLVING WHEN YOURE ON CALL How to work-up and manage Shortness of Breath How to work-up and manage Shortness of Breath