Approach To Breatheless Patient And Approach To Acute Chest Pain Flashcards
What is the percussion note of tension pneumothorax,pleural effusion,pneumonia
How do you take care of an aortic dissection patient(you’re supposed to know the treatment of all the lethal diagnosis )
Hyperresonant ,Stony dull,dull
Refer aortic dissection patient after controlling the BP (make it drop to 100-120mmHg) and heart rate but the heart rate is more important to control
Slow HR w beta blockers to as low as 60bpm . Go as low as is tolerable for the patient so if patient is breathless at 65bpm,don’t say you have to drop it to 60 so by force it should drop.
If the beta blockers don’t end up taking care of the bp,reduce it using anti hypertensives (I think that’s what he said)
What is breathlessness
What are the systems that case dyspnea on exertion,dyspnea when eating (and why), dyspnea at night,dyspnea due to hormones
What’s the difference between hyperventilation and hyperpnea and tachypnea
Subjective awareness of reduced breathing. Ask patient what they mean by they can’t breathe cuz sometimes they confuse palpitations w dyspnea
dyspnea on exertion- cardiac or respiratory
dyspnea when eating - anemia can cause this and heart failure too cuz when you eat you increase oxygen demand on your body
dyspnea at night- asthma,heart failure
dyspnea due to hormones - pregnancy
Hyperpnea is breathing more deeply but not necessarily faster. It happens when you exercise or when you’re doing something strenuous. Hyperventilation is breathing very fast and deeply, and exhaling more air than you take in. Tachypnea is the term that your health care provider uses to describe your breathing if it is too fast, especially if you have fast, shallow breathing from a lung disease or other medical cause. The term hyperventilation is usually used if you are taking rapid, deep breaths.
What are the causes of breathlessness (five cardiac, five respiratory, non cardiac and non respiratory causes) and give things that can cause breathlessness in these major causes
What’s the ddifferencebetween hypoxia and hypoxemia
Cardiac causes: HF,pericarditis,cardiac ischemia,cardiac tamponade,MI,PE,arrhythmia ,mechanical vascular obstruction,anemia
Respiratory causes: pneumonia,pleural effusion,asthma,COPD ,Obstruction of airway,pneumothorax ,pulmonary edema ,interstitial lung diseases
Both systems causing it
Non cardiac non respiratory causes: Acute liver failure which leads to metabolic acidosis , Acute renal failure
(metabolic acidosis), High cervical cord lesions,Trauma to phrenic nerves,myasthenia Gravis , Portopulmonary
hypertension
Hepatopulmonary
syndrome,ascitis
Psychogenic causes : patients can intentionally induce seizures or breathlessness. Patients with hysteria will intentionally induce breathlessness
Metabolic causes : acidosis ,sepsis can cause acidosis
Hypoxia which can cause breathlessness means a state of low oxygen in the blood
Hypoxemia: low oxygen in the blood
How do you manage patients who nearly drowned and patients who tried to gang themselves but didn’t die
What is a characteristic of pulmonary embolism and heart failure breathlessness concerning onset
Detain them for days cuz they can have negative pressure pulmonary edema causing airway obstruction leading to edema
PE- sudden breathlessness So All sudden breathlessness is PE until proven otherwise HF- progressive or gradual Breathlessness
How do you manage a patient w breathlessness
Don’t give fluids to malnourished kids unless they’re in shock(10 mls per kg). True or false
Use this case scenario as a guide, 50yo
Woman who returned from an airplane trip with right leg cramps . Husband massaged her leg and the next day all of a sudden she felt breathless. Vitals- HR- 121bpm,90/60mmHg,85% on non rebreather mask,temp-36.7,RBS-10.4
Same approach for undifferentiated patient cuz you don’t know what’s causing the breathlessness
True
Ensure safety
Is patient looking sick(in this case yes)
Call for help
If sick,set a line,put on O2 and on cardiac monitor.
A- ask patients name and call it to check for airway latency
B- spo2 is low so move to a higher delivery device and according to the scenario it’s CPAP (continuous positive airway pressure) which as a PA you won’t have in your facility so refer as you’re doing the assessment. (Dr Asamani is also saying intubate so idk)
Check air entry . In this case it’s symmetrical
C- pulse ,neck veins,bp,capillary refill
This patients neck veins are distended
Pulse is high and bp is low so shock may be present
In this case it’s an obstructive shock causing a massive PE
Take samples for investigations such as D dimer, FBC,BUE Cr,
But ultimately you’ll have to treat with thrombolytic such as altipase
D- GCS ,pupils and other things
E- do it
Make sure you finish the whole assessment even when you find the diagnosis at maybe C or D or even B
State five signs of airway obstruction
What are the accessory muscles (inspiratory and expiratory)and what’s the difference between PE and massive PE
Confusion Violent coughing. Struggling to breathe. Turning blue. Choking. Gagging. Vomiting. Wheezing. Aggressiveness
The accessory inspiratory muscles are the sternocleidomastoid, the scalenus anterior, medius, and posterior, the pectoralis major and minor, the inferior fibres of serratus anterior and latissimus dorsi, the serratus posterior superior may help in inspiration also the iliocostalis cervicis
The accessory expiratory muscles are the abdominal muscles: rectus abdominis, external oblique, internal oblique, and transversus abdominis
What are the six lethal causes of chest pain
Rule them out before you check other ddx
You don’t refer patient unless you’re done w your initial assessment .
So until assessment,check for lethal diagnosis and treat accordingly
What’s the difference between cardiac tamponade and tension pneumothorax
MI- cardiac chest pain,high cholesterol,St elevation,elevated cardiac enzymes
Aortic dissection: very rare but deadly. Very High blood pressure ,tearing chest pain radiating to the back. Aortic dissection can present as stroke and MI,check bp in right hand and left hand and if diff in systolic bp is more than 20mmHg it’s aortic dissection ,asymmetrical pulses
Do at least X ray before you start treatment for MI and if there’s a widened mediastinum then the aorta is torn so aortic dissection so don’t give aspirin.
Pulmonary embolism:sudden onset chest pain and sudden breathlessness,sudden collapse,spo2 is low ,one sided chest pain where the clot is,pleuritic chest pain when they take in deep breaths
Risk factors for this: obesity,always lying down or always sitting down,pregnancy
Things needed to form a clot:stasis,hypercoagubule state,vessel damage
Tension pneumothorax:(coughing and sudden breathless is spontaneous pneumothorax) but it’s tension is there are distended neck veins,tracheal shifting away from the affected side,hyper resonance, air entry is reduced at affected side,hypotension Tension pneumothorax diagnosed on an x ray is a late diagnosis and is a clinical diagnosis . Will cause an obstructive shock . Put large ball cannula in second intercostal space to relieve the tension
Cardiac tamponade: fluid around heart prevents it from filling and collecting blood to circulate to the body. Fluid around the heart isn’t tamponade it’s pericardial effusion. But if it impairs cardiac function as in preventing right ventricular filling it’s a tamponade . Has nothing to do w volume of fluid cuz you can have a big amount of fluid and no tamponade . It has to do with the rate of filling . Ultrasound shows you
But you can diagnose it clinically using Beck’s triad: distended neck veins,hypotension,distant heart sound . Give IV fluids cuz the problem is the right heart has collapsed so preload is reduced . Do chest X ray and you’ll see bottle shaped heart . You’ll see electrical alternans on ECG(Electrical alternans is an electrocardiographic phenomenon of alternation of QRS complex amplitude or axis between beats and a possible wandering base-line. Electrical alternans is defined as alternating QRS amplitude that is seen in any or all leads on an electrocardiogram (ECG) with no additional changes to the conduction pathways of the heart. )
Oesophageal rupture: risk factors:excessive vomiting and retching found in alcoholics who are having hangovers and vomiting all over the place or patient with blunt neck injury
Clinical feature: subcutaneous emphysema(Subcutaneous emphysema is the medical term for air becoming trapped in tissues beneath the skin. ) on chest. It is usually seen in punctured lung. X ray: air in mediastinum . History:
Tamponade will typically reveal clear, bilateral, lung sounds while a tension pneumothorax will not.
How will you approach a patient w chest pain
Case scenario,30 year old man w CKD on dialysis presents w progressing worsening chest pain of three days
Vitals-37.6,112bpm,90/50mmHg,RR-23cpm,99%,6.0 RBS
2.Known non compliant hypertensive Sudden onset of tearing chest pain radiating to the back ,he appears diaphoretic(sweating profusely.)
Is this chest pain a cardiac chest pain or non cardiac chest pain
Is patient looking sick
If yes IvO2monitor
Begin initial assessment (looks for immediate life threatening things that can cause their death):
Make sure the scene is safe or it’s safe for you to proceed example if patient is lying in water,get patient out
A-Airway patency
B-air entry is reduced on the right (you’re to check if air entry is symmetrical or not,breathing and spo2)
C-
Sample history
Take focus pain history on what’s causing the pain . ODQ will talk about finding the lethal ddx . If you don’t find these ddx
Go do full history and full ddx to find what’s causing the chest pain
2.B-air entry is symmetrical and spo2 is 99%
C-200/190mmHg in the right ,put in large ball cannulas and take samples ,120bpm pulse rate
Give antihypertensive to reduce the bp
Will you give oral or IV hypertensives?
IV cuz you want it to work fast
Hypertensive urgency and hypertensive emergency
What are the causes of chest pain
Refer a patient when you suspect something bad . Anticipate the worst case scenario. Plan early referral if you think you can’t treat patient
CVS:MI,aortic dissection,pericarditis,myocarditis,severe aortic stenosis,pulmonary embolism
Respiratory:pleuritic chest pain,pneumonia,pneumothorax,pleural effusion
GIT:gerd,eosophagitis,oesophageal rupture
Musculoskeletal :musculoskeletal chest pain , Costochondritis (kos-toe-kon-DRY-tis) is an inflammation of the cartilage that connects a rib to the breastbone (sternum) s. Costochondritis is sometimes known as chest wall pain, costosternal syndrome or costosternal chondrodynia. Sometimes, swelling accompanies the pain (Tietze syndrome),
Tearing chest pain w high bp means?
Characteristic of cardiac chest pain?
What is the characteristic of pericarditis pain
What are the ddx of central ,crushing, restrosternal chest pain that radiates to the left arm ,shoulder or occiput and can radiate to right arm and in elderly patients and Diabetics won’t have signs of chest pain but have MI
What are the characteristics of coronary artery disease
And acute coronary syndrome
Difference between NonSTEMI ,unstable angina and STEMI
Aortic dissection – Patients often describe a tearing chest pain that radiates into the back between the scapular spines.
Pain brought on by activity and relieved by rest
It usually feels sharp or stabbing. However, some people have dull, achy or pressure-like chest pain.
Pericarditis pain usually occurs behind the breastbone or on the left side of the chest. The pain may:
Spread to the left shoulder and neck
Get worse when coughing, lying down or taking a deep breath
Get better when sitting up or leaning forward. Fever can be seen in this patient too.
Stable,unstable,NonStemI(Non ST elevated MI),STEMI(ST elevated MI)
Acute coronary syndrome:1.Unstable,2.NStemI,3.STEMI
NonstemI: pleuritic chest pain w elevated cardiac enzymes,no ST elevation (meaning there’s no complete occlusion of the vessel)
STEMI:ST elevation(tells you that there’s complete occlusion of the vessel that supplies that particular part of the heart),chest pain,elevated cardiac enzymes (shows there’s myocardial injury)
Unstable angina:Normal ECG,normal cardiac enzymes, but has chest pain
12-YEAR-OLD BOY IS SAID TO HAVE FALLEN 4 DAYS AGO WHILES BLAYING FOOTBAL. A DAY LATTER , HE STARTED COMPLAINING OF RIGHT CHEST PAINS ASSOCIATED WITH FEVER. MOTHER ALSO NOTED THAT HE WAS BREATHING FAST AND LAST NIGHT BECAME MORE BREATHLESS WHEN HE LIES FLAT. HE HAS BEEN BROUGHT TO YOUR FACILITY FOR ASSESSMENT AND TREATMENT.
HOW WILL YOUR HANDLE THIS CASE?
ABCDE
Iv O2 monitor
When investigations come we’ll treat the cause
But ddx for this case is pneumonia,flail chest,right haemothorax,pneumothorax,haemopneumothorax
Investigations include chest x ray FBC BUE Cr
So pt comes in breathless
What’s the approach?
Same as undifferentiated
Is patient looking sick?
If yes do Iv O2 monitor
ABCDE
Sample history
Initial ddx and investigations
And initial treatment
Secondary assessment
Final ddx and investigations
So for the SaQ
It is basically a clinical vignette
With 5 subquestions
Eg.
A 70 year old male unrestrained front seater of a taxi was involved in a head collision motor vehicle accident and presents ti your facility with breathlessness and chest pains.On examination, spo2 is 87%on nasal prongs and had reduced ae on the right with reduced chest movement on the ipsilateral side.Percussion note is hyper-resonant to Neck veins seems distended and trachea is deviated to to the contralateral side
A- list five differentials of his chest pain and breathlessness
B-What is the most likely diagnosis and why
C- outline your immediate management.
D- list 2 the diagnostic investigstions and their associated expected findings
E- u are having difficulty assessing a perepheral line so u decide to do an IO.
-list 3 IO sites And 2 contraindications
Solve this scenario
Difference between difficulty breathing in cardiac problems and difficulty breathing in resp problems
Cardiac;
Reduced urine output
Raised jvp
All those cardiac things positive
Difficulty breathing precedes cough if any
Patient benefits from diuretic use
Resp:
Normal urine output
No change in pt status with diuretic use
No orthopnea
No cardiac signs and symptoms s
What organism causes croup?
Which causes Bronchiolitis ?
Parainfluenza virus most commonly causes viral croup or acute laryngotracheitis, primarily types 1 and 2. Other causes include influenza A and B, measles, adenovirus, and respiratory syncytial virus (RSV). Spasmodic croup is caused by viruses that also cause acute laryngotracheitis, but lack signs of infection.
Bronchiolitis is usually caused by the respiratory syncytial virus (RSV).
