Differential Diagnosis - Allergies, Non-Traumatic Pain, Respiratory Flashcards
Anaphylaxis vs Allergic Reaction
Anaphylaxis: widespread multisystem reaction or severe reaction in a singular system
Allergic Reaction: involves one organ system or one local area
Typical body systems involved in allergic reactions
Integumentary: hives, itching, flushing, swelling, angioedema
Cardiovascular: increased HR, decreased BP, syncope (due to low BP), decreased LOA (lack of perfusion)
Respiratory: SOB, wheeze, cough (esp. in kids this is huge), stridor, tachypnea
Gastrointestinal: cramping, N/V/D
Treatment for allergic reactions
epinephrine
diphenhydramine
What is cardiac ischemic chest pain?
chest pain caused by an imbalance between the blood supply to the heart and oxygen needs of the heart muscle (ischemia)
Chest pain differentials for cardiac ischemic chest pain
- MI - STEMI or NSTEMI
- Angina
- unstable angina
- coronary artery dissection
- coronary artery embolism
*in the field, it’s likely difficult to differentiate between coronary artery dissection vs embolism (and others). Mostly just helps with figuring out tx (i.e. cardiac ischemia directive or not)
Chest pain differentials for non-ischemic cardiac chest pain
- pericarditis, myocarditis, endocarditis
- aortic dissection
- pulmonary embolism
- pleural effusion (buildup of fluid in pleural cavity)
- Pericardial effusion, cardiac tamponade
- Gastritis, GERD, Esophageal rupture
- Rib fracture, bone lesions
- anxiety
What are relevant chest pain questions to ask?
-
OPQRST
-
O: Pain brought on by exertion and relieved with rest (angina)
- Pain that continues to increase from onset - potentially MI
-
P: if it gets better, not MI
- gastritis can get better with sitting up (as well as rib fracture, anxiety)
- pleural effusion - don’t like to lie down
- increases with inspiration (PE)
-
Q: ripping/tearing (dissection)
- sharp (PE)
- ache/full/pressure/elephant on chest/crushing (MI, angina) unless previous dx of atypical chest pain Sx
- feelings like indigestion/GERD but nothing is resolving it
-
R: into the back (AAA)
- jaw, neck, back (MI/angina)
- S: used for nitro - stop once you get to 0/10 pain
- T: constant or intermittent; if resolves with rest (angina). Intermittent is probably noncardiac in nature
-
O: Pain brought on by exertion and relieved with rest (angina)
- Risk Factors - sedentary lifestyle, high cholesterol, smoking, genetics, diabetes, family hx, age
- Meds – which and why?
- Similar episodes in the past? What was the dx or outcome?
- Drug use? Specifically? - cocaine (heart beating so fast that there is poor perfusion leading to ischemia)
- Palpitations? considering SVT, uncontrolled a-fib in elderly
- Suspecting PE? - Recent surgery? Sedentary? Travel?
Assessments considered for chest pain
- Cardiac monitor
- 12-lead
- auscultation
- pallor, diaphoresis
- JVD - for cardiac tamponade, heart failure
- BP in both arms - AAA
12-lead indications
- syncopal patients or near syncopal
- anyone with chest pain
- epigastric gain
- back/neck pain (unless trauma)
- pulmonary edema patients
- SOB (with discretion)
- profound weakness (esp. in elderly population)
- diaphoresis unexplained by ambient temp
- diabetics that are suspecting DKA
______% of patients with STEMI present with chest pain
80% (1 in 5)____
Potential 12-lead findings for a PE
S wave in Lead I
Q wave in Lead III
inverted T wave in III
Chest pain treatments
- ASA
- Nitro
- STEMI bypass
- PAD application
- pain management (if not ischemic chest pain)
- N/V
STEMI Hospital Bypass Protocol: Indications
1) ≥18 years of age;
2) experience chest pain or equivalent consistent with cardiac ischemia or MI
3) time from onset of the current episode of pain <12 hours; and
4) the 12-lead ECG indicates an acute myocardial infarction/STEMI, as follows:
- At least 2 mm ST-elevation in leads V1-V3 in at least two contiguous leads; AND/OR
- At least 1 mm ST-elevation in at least two other anatomically contiguous leads; OR
- 12-lead ECG computer interpretation of STEMI and paramedic agrees.
STEMI Hospital Bypass Protocol: Contraindications
- The patient is CTAS 1 and the paramedic is unable to secure the patient’s airway or ventilate;
- 12-lead ECG is consistent with a LBBB, ventricular paced rhythm, or any other STEMI imitator;
- Transport to a hospital capable of performing PCI ≥60 minutes from patient contact;
-
The patient is experiencing a complication requiring primary care paramedic (PCP) diversion, as follows:
- Moderate to severe respiratory distress or use of CPAP
- Hemodynamic instability (e.g. due to symptomatic arrhythmias or any ventricular arrhythmia) or symptomatic SBP <90 mmHg at any point; or
- VSA without ROSC
-
The patient is experiencing a complication requiring ACP diversion, as follows:
- Ventilation inadequate despite assistance;
- Hemodynamic instability unresponsive to advanced care paramedic (ACP) treatment or not amenable to ACP management; or
- VSA without ROSC.
However notwithstanding (bolded) above, attempt to determine if the interventional cardiology program at the PCI centre will still permit the transport to the PCI centre;
As per STEMI bypass protocol, once you’re transporting the patient to the PCI center, what information do you have to tell PCI center?
- that the pt is a “STEMI patient”
- initials
- age
- sex
- paramedic’s concerns re: clinical stability
- infarct territory and/or findings on qualifying ECG
- ETA
- catchment area of pt pickup
As per STEMI bypass protocol, once you get to the PCI centre, what additional information would you provide?
- times of Sx onset
- time of ROSC (if applicable)
- hemodynamic status
- meds given and procedure
- Hx of acute MI/PCI/CABG, if applicable
- a copy of the qualifying ECG
- a copy of the ACR
Guidelines as per the STEMI Hospital Bypass Protocol
Once a STEMI is confirmed, the paramedic should apply defibrillation pads due to the potential for lethal cardiac arrhythmias.
If IV access is indicated and established as per the Advanced Life Support Patient Care Standards, then the left arm is the preferred site.
If the ECG becomes STEMI-positive en route to a non-PCI destination, the patient should still be evaluated under this STEMI Hospital Bypass Protocol.
If, in a rare circumstance, the PCI centre indicates that it cannot accept the patient (e.g. equipment failure, multiple STEMI patients), then the paramedic may consider transport to an alternative PCI centre as long as they still meet the STEMI Hospital Bypass Protocol.
Differentials for dyspnea - trauma
- pneumothorax
- hemothorax
- esophageal rupture
- blunt force trauma
- cardiac tamponade
- anything that can cause hypovolemia
Differential dx for dyspnea - nontraumatic
- COPD, asthma (differentiate between these two based on Hx and questioning)
- anxiety
- sepsis
- croup
What assessments should be considered for dyspnea complaints?
- auscultation - decreased air entry and adventitious sounds (wheezes, crackles)
-
positioning
- tripoding (creates line for airway to get more air in), sitting up
- SpO2
- ETCO2
- Head/Neck: cyanosis, excessive drooling & nasal flaring (esp. in peds), JVD, tracheal deviation
- Chest: subQ emphysema, accessory muscle use, urticaria, indrawing, shape (barrel chested for COPD), symmetry, tenderness
- Extremities - cyanosis, edema
Describe the following phases as labeled in the diagram
A-B: dead space - not breathing (just before exhalation)
B-C: exhalation
C-D: peak of exhalation (plateau)
D: actual ETCO2 value
DE: zero CO2 in the body (when inhaling)
Describe what may be happening to the patient based on these waveforms
4a: ROSC (if it’s a super tall spike) or you’ve got better airway placement
4b: placement problem
4c: good waveform
4d: lost airway
How does capnography change in bronchoconstriction?
shark fin waveform - the one waveform that is indicative of something going on (one of the key indicators that bronchoconstriction is occurring )
How does capnography change in CHF?
- initially - they will try to compensate with BP and RR increase which would drop your ETCO2 below 35 likely (so a CHF patient with normal RR and BP means they are compensatory)
- over time, thy will start to retain CO2 because less gas exchange area - so normal or elevated BP and elevated ETCO2 means resp failure is starting
-
Tombstone shape - patient condition deteriorating and may be going into cardiogenic shock (pulmonary edema, hypotensive and high ETCO2)
- In cardiogenic shock, less blood is circulated to the lungs and less CO2 is eliminated. If the patient is hypotensive with pulmonary edema, and ETCO2 is low, below 35 mm Hg, this indicates inadequate tissue perfusion
- The capnograph may also have a rounded “tombstone” shape in low perfusion states
What is the purpose of using capnography in cardiac arrest?
- Tells you if you’re doing a good job
- ETCO2 >10mmHg is good for VSAs as long as there is a decent waveform
- adequate CPR x advanced airway x 20 mins (since pt has been down), if <10 mmHg then patient will have a poor outcome
- However, adequate CPR + advanced airway + 20 minutes (20 minutes of good CPR with ETCO2 ≧15, you are probably not getting a TOR)
What are tracheal breath sounds?
- heard over the trachea - above subclavicular notch
- Loud, harsh, high pitch - like blowing air through a pipie
- Inspiratory and expiratory length are equal
What are bronchial breath sounds?
- Present over manubrium – just above clavicles
- High in pitch
- Louder and more tubular and hollow sounding than vesicular
- Inspiratory shorter than expiration phase
- Short gap between inspiration and expiration
What are bronchovesicular breath sounds?
- Heard in the 1st and 2nd intercostal spaces next to the sternum and
- between the scapula
- Softer pitch than bronchial sounds
- Equal during inspiration and expiration
What are vesicular breath sounds?
- Soft, blowing or rustling sounds
- Heard normally throughout most of the lung fields
- Normally heard throughout inspiration, no pause and then fade away about 1/3 of the way through expiration
