ACUTE DYSPNEA AND RESPIRATORY DISTRESS

Question 1

GENERAL MANAGEMENT

Answer 1

1. Position Patient
2. Oxygen (~94%)
   OXYGEN MODALITIES
   Nasal cannula: up to 6 L/min can be delivered at an FiO2 of 40%.
   Non-rebreather: FiO2 up to 90%.
   High-flow nasal cannula: up to 60 L/min
3. IV Access
4. Cardiopulmonary Monitor
5. Airway and Resuscitation Equipment at bedside
6. PRIMARY SURVEY

A - STRIDOR.

Assess IMPENDING RESPIRATORY FAILURE and INDICATIONS FOR DEFINITIVE AIRWAY
Loss of oxygenation and/or ventilation
Inability to protect airway
Impending upper airway obstruction
Risk of clinical decompensation without secured airway

Caution in: Status Asthmaticus, Acute / Submassive / Massive Pulmonary Embolism, Pulmonary Hypertension, Severe Metabolic Acidosis

B - RESPIRATORY RATE. >/ 30, 02 sats 90% on Fi02 30%.
Note:
Work of breathing.
Tracheal Position.
Chest wall crepitus / chest rise.

C - MOTTLED APPEARANCE
Note:
GCS
Pallor
Extremity Warmth
Cap Refill
Distal Pulses
Palpate Abdomen.

D - CHECK GLUCOSE.
Note:
GCS
PERRLA
lateralizing signs

E - EXPOSURE, TAKE DOWN DRESSINGS

7. BRIEF HISTORY
   Allergies
   Medications
   PMHx
   Last Meal
   Events Leading up to Presentation
8. POCUS: RUSH EXAM

Heart: Subxyphoid
IVC
Morrison’s Pouch
Aorta
Pulmonary (Respiratory Distress)

Advanced Cardiac: PSL / PSS / 4CA

9. INTERVENTIONS

HEMODYNAMIC INSTABILITY
POCUS & Rule Out Life Threatening Causes:
Tension PTX (Thoracostomy)
Massive PE (Thrombolytic)
Tamponade (Pericardiocentesis)

IMPENDING RESPIRATORY FAILURE: EMERGENT AIRWAY MANAGEMENT
Anaphylaxis -> IM Epinephrine
Intubation: Loss of oxygenation or ventialtion, loss of respiratory drive, airway protection
Cricothyrotomy:
Unable to oxygenation, ventilate and intubate. Upper Airway Obstruction
NIPPV: Able to protect airway. COPD, CHF.

INVESTIGATIONS
CBC
Lytes
Urea / Cr
ABG / VBG
Lactate
Trops
Procalcionin
+/- BNP
+/- D-Dimer
Toxicology
ECG
CXR
Bedside Echo

Question 2

SPECIFIC MANAGMENT

Answer 2

ACUTE CORONARY SYNDROME
Aspirin, antiplatelet, heparin, nitroglycerin

Percutaneous coronary intervention in <90 minutes

If catheterization is unavailable for ST-elevation myocardial infarction:

Tenecteplase (TNK-tPA)
Reconstitute 50-mg vial in 10 mL sterile water (5 mg/mL)
Single weight-based bolus, IV push over 5 seconds
<60 kg: 30 mg
60-69 kg: 35 mg
70-79 kg: 40 mg
80-89 kg: 45 mg
>90 kg: 50 mg

Special Considerations:
Avoid nitroglycerin in right ventricular infarction
Monitor for arrhythmia

ACUTE CHF
Non-invasive positive pressure ventilation
IV diuresis (furosemide 20-200 mg IV)
IV nitrate bolus and/or infusion (nitroglycerin or nitroprusside)

Special Considerations:
Dose of diuretic dependent on prior diuretic use and renal function
Can redose diuretic based on response
Titrate nitrate dose to blood pressure

Question 3

DOCUMENTATION

Question 4

DDX: MOST COMMON CAUSES

Answer 4

OTHER: 28.6%
Pneumonia: 20.2%
CHF Exacerbation: 15.0%
COPD Exacerbation: 13.6%
Asthma Exacerbation: 12.7%
ACS: 3.1%
Arrythmia: 2.6%
Pleural Effusion: 2.2%
Pulmonary Embolism: 1.0%
Pneumothorax: 0.9%

Question 5

DDX

Answer 5

SHOCK:
Tension PTX
Massive PE
Tamponade

RESPIRATORY FAILURE:
Airway Obstruction
Respiratory Failure (Hypoxic / Hypercarbic)
Anaphylaxis

PULMONARY:
Pneumothorax
Pneumonia
Asthma
COPD Exacerbation
ILD

VASCULAR:
Pulmonary Embolisms

CARDIO:
Arrythmia
MI
CHF
Pulmonary Edema
Pleural Effusion
Pulmonary Hypertension

HEME:
Anemia

DRUGS:
Opiates, benzodiazapine, ASA, organophosphates

METABOLIC / TOXIC:
CO poisoning, Thyrotoxicosis

NEUROMUSCULAR DISEASE
Myasthenia Gravis
Guillain-Barre
Botulism