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

2. 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

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

4. 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?

5. Phone Call Oxygen 1 L/min O2 on NC adds 3% FiO2 on RA for CO2 retainers, start with 3-4 L/min, FiO2 29-32% 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, FiO2 29-32% for asthma/COPD, aerosol treatment ABG?

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

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

8. 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)

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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

20. Causes of Shortness of Breath A quick review

21. 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

22. 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

23. 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

24. 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)

25. 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

26. 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

27. 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