1. ED training Respiratory/ patient with dyspnea Dr Jaycen Cruickshank Emergency Medicine Training Hub Ballarat & Grampians Region 2012

2. Respiratory - dyspnea Learning objectives The respiratory session will examine contrasting clinical cases of dyspnoea that will illustrate the principles of diagnostic reasoning. lmportant physical findings that help discriminate different causes of dyspnoea will be discussed along with appropriate initial investigations. Learning objectives Be able to describe the differences and similarities in the medical history, physical examination and investigations of common or life threatening causes of dyspnoea. To manage asthma and pneumonia using best practice guidelines To be able to use the Wells score & PERC rule in diagnosis of PE Pre reading Hughes T & Cruickshank J. Adult Emergency Medicine at a Glance. Chichester, West Sussex, UK : John Wiley & Sons, 2011. Chapter 36 Shortness of breath. Chapter 7 Blood gas analysis. Other learning resources Relevant clinical clinical guidelines at Ballarat Health Services: Refer to ED lecture series and self directed workbooks

3. Other learning resources http://www.mdcalc.com/wells-criteria-for-pulmonary-embolism-pe/ Wells et al. Excluding pulmonary embolism at the bedside without diagnostic imaging: management of patients with suspected pulmonary embolism presenting to the emergency department by using a simple clinical model and d-dimer. Ann Intern Med. 2001 Jul 17;135(2):98-107. http://www.ncbi.nlm.nih.gov/pubmed/11453709Ann Intern Med.http://www.ncbi.nlm.nih.gov/pubmed/11453709 Written asthma action plans. http://www.nationalasthma.org.au/managing- asthma/controlling-your-asthma/written-asthma-action-planshttp://www.nationalasthma.org.au/managing- asthma/controlling-your-asthma/written-asthma-action-plans Pneumonia severity scoring systems for community-acquired pneumonia in adults (Appendix 2.4) http://jasper.tg.com.au/complete/tgc/abg/8052.htmhttp://jasper.tg.com.au/complete/tgc/abg/8052.htm http://lifeinthefastlane.com/2009/11/a-classic-respiratory-case/

4. Preparation slides These may be pre reading +/- presented by teacher The first part of this presentation is designed to be pre reading. Learners are encouraged to do some reading before the tutorial The slides may be presented briefly at the start of a session to recap Your hospital should have some clinical guidelines which will provide relevant local information

5. Emergency Department HMO education series 2012 How do we make a diagnosis in a patient with dyspnea? History Cardinal features Associated features Risk factors (for diseases), past history (known diseases), respiratory reserve “what can do usually?” Examination findings Suitable/targeted investigations CXR, ECG, ABG’s, basic bloods Lung function, CT, VQ, exercise test, echo

6. Emergency Department HMO education series 2012 A focussed history determines both diagnosis and severity. SOB + associated symptoms suggests a cause or differential diagnosis SOB + Pleuritic pain= Pneumonia, pneumothorax SOB + wheeze = Asthma, COPD SOB + stridor = Inspiratory obstruction e.g croup SOB + fever/cough/sputum = Pneumonia, other infection SOB + haemoptysis Upper airway cause, Pneumonia, PE, cancer, vasculitis The severity of symptoms E.g is the person breathless at rest, on exertion Certain features aid diagnosis Acute onset Pneumothorax, PE, AF, APO, asthma Gradual onset or with exertion Cardiac cause, chronic anaemia Worse at night, or lying down Cardiac failure

7. Background history Would you prefer to know risk factors for disease or known diseases? Exacerbations of known diseases are common and the diagnostic challenge is likely to focus on precipitant, and the severity of the consequences of the exacerbation Ask about Medications, including doses, compliance, recent changes Who normally looks after the patient and where Is there access to a good summary of recent treatment – think the GP, specialist clinic letters, recent admissions As you build up a differential diagnosis, ask questions that are relevant to each differential e,g I am thinking PE, so I will ask about recent travel, perhaps use the Well’s criteria I am thinking pneumonia, I might ask about hospital vs community acquired, immunosuppresion, contacts, birds, known recent outbreaks e.g Legionella I am thinking what should I not miss, e.g cardiac causes This type of approach to differential diagnoses is often helpful when working through a list of possible diseases.

8. Emergency Department HMO education series 2012 Paediatrics A quick reminder that for paediatric assessment, there are resources available to assist with normal values Hypoxia needs immediate correction, remember cyanosis a pre terminal sign in children Most of the examination can be completed without O2 sats or a stethoscope using observation

9. Emergency Department HMO education series 2012 You need to be familiar with this for winter. Standardised way to assess, present, refer kids. The Royal Children’s clinical guidelines are an excellent resource to look up while working in the Emergency Department. http://www.uhs.nhs.uk/Media/suhtideal/TopNavigatio nArticles/SkillsForPractice/ClinicalSkills/paediatricas sessment.pdf http://www.uhs.nhs.uk/Media/suhtideal/TopNavigatio nArticles/SkillsForPractice/ClinicalSkills/paediatricas sessment.pdf Recognition of the seriously ill child http://paeds.org/apls/aplsrecog.html the structured approach to the seriously ill child http://www.paeds.org/apls/aplsapp.html http://www.paeds.org/apls/aplsapp.html

10. Clinical cases to demonstrate We have a very thorough powerpoint presentation that contains more detail, a very methodical approach. Highly recommended. The rest of this presentation will contain some cases. A further series of cases will be presented at the actual teaching session.

11. Emergency Department HMO education series 2012 Case A A young man presents to the Emergency Department via ambulance He complains of sudden onset of SOB. Present for a few hours and now quite severe.

12. Emergency Department HMO education series 2012 Further history Previously well, smokes 10 cigarettes/day Left sided chest pain Moderate Pleuritic Started with the SOB Is there anything else you would like to ask? What is your ddx?

13. Emergency Department HMO education series 2012 Differential diagnosis Pneumothorax Arrhythmia Pulmonary Embolism Asthma (less likely) Much less likely Pneumonia Not to be mentioned before all organic causes considered anxiety Imagine that being your diagnosis and you missed the pneumothorax…

14. Emergency Department HMO education series 2012 Examination findings Looks unwell, quite distressed with  WOB RR 26, HR 125 SR, BP 80/60, afebrile Saturation 93% RA (room air) Trachea midline  chest expansion on the left Hyperesonant percussion note on the left  air entry left lung What is going on? Is this serious? What is your immediate management?

15. Emergency Department HMO education series 2012 Describe this CXR … ideally this intervention before this CXR…

16. Emergency Department HMO education series 2012 Diagnosis and management? Initial therapy? Who will help you? Where you are working, will you call a MET, ask for senior help? Urgent chest tube (this may have even been done without a CXR if the patient was unwell enough)

17. Emergency Department HMO education series 2012 Describe this CXR See notes for report

18. Emergency Department HMO education series 2012 Describe this CXR

19. Emergency Department HMO education series 2012 Case B Young man Brought to the ED by his partner Progressive SOB over 48 hours. Now present at rest How is your differential diagnosis altered by the gradual onset? Asthma Pneumonia Other?

20. Emergency Department HMO education series 2012 Further history & examination Wheeze Dry cough Recent URTI Childhood asthma (age 3-12), hay fever No cardiac history No risk factors for PE RR 24, HR 110 SR, BP 110/70 Sat 97% RA Widespread wheeze (what causes this sound?)

21. Emergency Department HMO education series 2012 Investigations If the CXR is normal… Peak Flow 300/min (how does this help us?) ABG ph 7.5/CO2 30/O2 70/HCO3 23 What do the blood gases show? How severe is the problem What if the CXR not normal, as seen on right Does it exclude asthma?

22. Emergency Department HMO education series 2012 Diagnosis is asthma: The treatment plan is easy, but can you document it well? Bronchodilators, corticosteroids, oxygen Describe the stickers used to standardise prescribing in the ED at Ballarat Health Services Describe a safe asthma discharge plan What are asthma action plans? http://www.nationalasthma.org.au/health-professionals/tools-for-primary-care/asthma-action-plans/asthma-action- plan-library http://www.nationalasthma.org.au/health-professionals/tools-for-primary-care/asthma-action-plans/asthma-action- plan-library

23. Emergency Department HMO education series 2012 What scoring tools for pneumonia? CURB-65, SMARTCOP? How do scoring tools help predict: Need for admission, and appropriate ward Antibiotics and route Mortality Is it acceptable to write clinical notes on a patient with a diagnosis of pneumonia and not document severity using one of these tools? No Various website and apps can assist you in remembering them. www.mdcalc.comwww.mdcalc.com

24. Further cases… To be presented at the teaching session. See part 2 & 3