ABCD-Dyspnoea - BHS Education...
100
ABCD-Dyspnoea Dr Steve Costa Emergency Medicine Training Hub Ballarat & Grampians Region
Transcript of ABCD-Dyspnoea - BHS Education...
ABCD-Dyspnoea
Dr Steve Costa
Emergency Medicine Training Hub
Ballarat amp Grampians Region
Notes for next time
Slide 43 onwards ndash clean up regarding the
XRs confusing in lecture
PE ndash ECG discussion
Learning objectives
Explore familiar material (mostly)
Diagnostic reasoning
Be able to describe the differences and similarities in the medical history
physical examination and investigations of common or life threatening
causes of dyspnoea
Pre reading
Hughes T amp Cruickshank J Adult Emergency Medicine at a Glance
Chichester West Sussex UK John Wiley amp Sons 2011 Chapter 36 -
Shortness of breath Chapter 7 - Blood gas analysis
Refer to ED lecture series and self directed
workbooks
Learning resources
httpwwwrchorgauclinicalguide
httpwwwmdcalccomwells-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 17135(2)98-107 httpwwwncbinlmnihgovpubmed11453709
Written asthma action plans httpwwwnationalasthmaorgaumanaging-
asthmacontrolling-your-asthmawritten-asthma-action-plans
Pneumonia severity scoring systems for community-acquired pneumonia in adults
(Appendix 24) httpjaspertgcomaucompletetgcabg8052htm
httplifeinthefastlanecom200911a-classic-respiratory-case
Emergency Department HMO education series
2012
Dyspnoea ndash The lsquowork uprsquo
History
Cardinal features
Associated features
Risk factors (for diseases) past history (known
diseases) respiratory reserve ldquowhat can the patient
do usuallyrdquo
Examination findings
Inspection Palpation Percussion Auscultation
Suitabletargeted investigations
CXR ECG ABGrsquos basic bloods
CTCTPA VQ Lung function exercise test echo
Emergency Department HMO education series
2013
Diagnosis and severity
SOB + associated symptoms = cause or differential diagnosis
SOB + stridor = Inspiratory obstruction eg croup FB
SOB + Pleuritic pain = PE Pneumonia pneumothorax
SOB + wheeze = Asthma COPD lsquocardiac asthmarsquo or APO
SOB + fevercoughsputum = Pneumonia other infection APO
SOB + haemoptysis = Upper airway lesion pneumonia PE cancer
vasculitis
The severity of symptoms
Current distress
Breathless at rest talking on exertion
Oxygen needs
O2 sats oxygen flow and delivery system
Rate of onset and subsequent lsquotrendrsquo
Previous experience of patient (ITU admissions)
Diagnosis and severity
Background history
Expanding on the detail for a differential diagnosis eg
PE - recent travel FHx Wellrsquos criteria PERC score
Eliciting the history for therapeutic guidance
Pneumonia - CURB-65 hospital vs community acquired
immunosuppression contacts incl animals and birds known
recent outbreaks eg Legionella
Ask about
Medications including doses compliance recent changes
Who normally looks after the patient and where
good summary of recent treatment Think the GP specialist
clinic letters recent admissionsdischarge summaries
Emergency Department HMO education series
2012
Paediatrics
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 only observation
The Royal Childrenrsquos clinical guidelines are an excellent
resource to look up while working in the Emergency
Department
httpwwwuhsnhsukMediasuhtidealTopNavigationArticlesSkil
lsForPracticeClinicalSkillspaediatricassessmentpdf
Emergency Department HMO education series
2013
Paediatrics
Cases
Emergency Department HMO education series
2013
Case A
2 yo presents to ED at 2200 with mother
Not distressed (child ndash mother anxious)
Stridor noted at triage
What is your differential
Emergency Department HMO education series
2013
What is your differential
Croup
FB
Epiglottitis
Upper airway massswelling
Functional
Emergency Department HMO education series
2013
Emergency Department HMO education series
2012
What else might you elicit in
the history
What else might you elicit in
the history Recent or current viral illness in child sibs or
kinderchild care
Similar events in the past
Immunisation history (How many doses of Hib and when)
Fluids and food intake
How parentcarer feels about behavior
Possible FB
Emergency Department HMO education series
2013
On review
Child becomes distressed when you
approach and attempt to examine
Remember
Emergency Department HMO education series
2013
Emergency Department HMO education series
2012
On review
Child becomes distressed when you
approach and attempt to examine
Emergency Department HMO education series
2012
On review
Child becomes distressed when you
approach and attempt to examine
St Gurnasty Infirmary Unpleasantshire Hospitals
Services Trust
Kill or be killed
On review
Child becomes distressed when you
approach and attempt to examine
Intercostal recession marked
Tracheal tug noted
Also note respiratory rate O2 requirements
Emergency Department HMO education series
2013
text
Croup
Emergency Department HMO education series
2013
Treatment
Steroids have been shown to decrease the length of hospital stay need for nebulised Adrenaline and
other interventions
Mild to Moderate Croup
Prednisolone 1mgkg AND prescribe a second dose for the next evening OR a single dose of
Oral Dexamethasone 015mgkg Observe for half an hour post steroid administration Discharge
once stridor-free at rest
Severe croup
Nebulised adrenaline (1 mL of 1 adrenaline diluted to 4 ml with Normal Saline or 5ml of adrenaline
11000)
AND
Give 06mgkg (max 12mg) IMIV dexamethasone
Emergency Department HMO education series
2013
Case B
22 yo man
Brought to the ED by his partner
Sudden onset of SOB
Now present for few hours
How is your differential diagnosis affected by
the sudden onset
Emergency Department HMO education series
2013
Further history
Previously well smokes 10 cigarettesday
Left sided chest pain
Moderate
Pleuritic
Started with the SOB
Is there anything else you would like to ask
What is your differential diagnosis
Emergency Department HMO education series
2013
Emergency Department HMO education series
2012
Differential diagnosis
Pneumothorax
Arrhythmia
Pulmonary Embolism
Asthma (less likely)
Pneumonia
Anxiety
Emergency Department HMO education series
2012
Differential diagnosis
Pneumothorax
Arrhythmia
Pulmonary Embolism
Asthma (less likely)
Pneumonia
Anxiety (Imagine that being your diagnosis and you missed a pound$^ your honour)
You horrible
little doctor
Emergency Department HMO education series
2012
Examination findings
Looks unwell quite distressed with WOB
RR 26 HR 125 SR BP 8060 afebrile
Saturation 93 RA (room air)
Trachea midline
chest expansion on the left
Hyper-resonant percussion note on the left
air entry left lung
What is going on
Is this serious
What is your immediate management
Emergency Department HMO education series
2012
Describe this CXR
Emergency Department HMO education series
2012
Describe this CXR
gt or lt 2cm
Where gt 2cm then pneumothorax is gt50 and is considered large
Emergency Department HMO education series
2012
Describe this CXR
Bigger image next slide
Tethered
lung
gt2cm
Right shift of
mediastinum
Air next to
pericardium
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)
Tension
bullLarge bore cannula 2nd intercostal space mid-clavicular line
If large non-tension
bullgt2cm rim (ie gt50)
bull14-18 G cannula safe triangle (or 2ICS if contraindicated) - aspirate
bullDrain 8-14 FG is usually adequate although 28 FG may be required with
mechanical ventilation
Other considerations
bullNo improvement with drain ndash suction cardiothoracic involvement
httpthoraxbmjcomcontent58suppl_2ii39full
httpssecurecollemergencymedacukcodedocumentaspID=6194
Describe the treatment for
Pneumothorax
httpwwwbrit-thoracicorgukPortals0GuidelinesPleuralDiseaseGuidelinesPleural20Guideline202010Pleural20disease20201020pneumothoraxpdf
Emergency Department HMO education series
2012
Case B2
22 yo 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
Emergency Department HMO education series
2012
Further history amp 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
11070
Sat 97 RA
Widespread wheeze
(what causes this
sound)
Emergency Department HMO education series
2012
Investigations
If the CXR is normal (ish)hellip
Peak Flow 250min (how does this help us)
ABG on room air pH 75 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
Emergency Department HMO education series
2012
Investigations
If the CXR is normalhellip
Peak Flow 250min (how does this help us)
ABG on room air pH 75 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
Emergency Department HMO education series
2012
BBH Asthma protocol
Emergency Department HMO education series
2012
Investigations
If the CXR is normalhellip
Peak Flow 250min (how does this help us)
ABG on room air pH 75 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
Emergency Department HMO education series
2012
Investigations
If the CXR is normalhellip
Peak Flow 300min (how does this help us)
ABG on room air pH 75 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
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 httpwwwnationalasthmaorgauhealth-professionalstools-for-primary-careasthma-action-plansasthma-action-
plan-library
Asthma sticker
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 httpwwwnationalasthmaorgauhealth-professionalstools-for-primary-careasthma-action-plansasthma-action-plan-
library
Discharge checklist
Follow up referral letter to GP
Copy of letter with patient (optional)
Current asthma action plan
Triggers identified
Medications prescribed including
Relievers-short acting B agonists
Preventers-steroids
Symptom controllers-long acting B agonists (if prescribed)
Ensure medications will last until arranged review
Spacer or other delivery systems available and patient
understands use and care
Asthma handouts given (patient information fact sheet)
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 httpwwwnationalasthmaorgauhealth-professionalstools-for-primary-careasthma-action-plansasthma-action-
plan-library
Example action plan
Emergency Department HMO education series
2012
Case B3
22 yo man
Brought to the ED by his partner
Gradual onset of SOB
Now present for few hours
What else do you want to know
Emergency Department HMO education series
2012
Further history amp examination
No wheeze
Productive cough
No recent URTI
Childhood asthma (age
3-12) hay fever
No cardiac history
No risk factors for PE
RR 34 HR 110 SR BP
8965
Sat 87 RA
Dull R base with coarse
crackles
Emergency Department HMO education series
2012
Investigations
The CXR is hellip
ABG on room air
pH 730 CO2 55
O2 70 HCO3 18
What do the blood gases
show
How severe is the
problem
Emergency Department HMO education series
2012
What scoring tools for
pneumonia
SMARTCOP CURB-65 Sepsis guidelines
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
SMARTCOP
SMARTCOP
SMARTCOP
CURB 65
Various website and apps can assist you in
remembering them wwwmdcalccom
Emergency Department HMO education series
2012
Case B4 - Female in her 60rsquos
Sudden onset SOB (present now for 1 hour quite
severe) right sided pleuritic chest pain
Mild fever
Right total knee replacement 3 days ago
persistent leg swelling since yesterday
Non-smoker
No previous cardiorespiratory disease
Emergency Department HMO education series
2012
What is the differential
diagnosis
Emergency Department HMO education series
2012
What is the differential
diagnosis
Most likely
PE
Next likely
Pneumonia
Less likely
Pneumothorax
Arrhythmia
AMI
Emergency Department HMO education series
2012
On examination amp tests
Tachypnoea and some WOB
RR 24 T 376 HR 110 BP 11070
Sats 93 RA
Chest clear with normal percussion and normal breath
sounds
CXR normal
ABG pH 75 CO2 30mmHg p02 62mmHg on RA
Most likely diagnosis
What are Wells criteria
What are Wells criteria
PERC
D-Dimer
What test do you want to do
Emergency Department HMO education series
2012
What can you see
Emergency Department HMO education series
2012
Filling defect R main pulmonary trunk
Emergency Department HMO education series
2012
Emergency Department HMO education series
2012
Case C Man in 60rsquos
Woke this am very SOB and distressed ndash called
ambulance
Progressive SOB over 6 months
Chronic cough
Usually with white sputum
Now worse with no change in sputum colour
No associated fever
SOB in night ndash gets up
Ankles swollen recently
Heavy smoker (35 pack years)
Admission to local hospital 612 ago with chest pains
Emergency Department HMO education series
2012
Differential diagnosis
CCF with acute exacerbation
Chronic obstructive pulmonary disease
(COPD) with acute infective exacerbation
Anaemia
Emergency Department HMO education series
2012
Exam amp investigationshellip
Unwell RR 36 T 368 HR 90 SR BP 180102
Satrsquos 88 RA
Evidence of work of breathing and use of accessory muscles (which are these)
Pursed lip breathing
Prolonged expiration with wheeze
ABG pH 728 pCO2 60 pO2 55 HCO3 26
What do these show
Do you want a CXR
Emergency Department HMO education series
2012
Emergency Department HMO education series
2012
Diagnosis
Acute cardiac failure ndash APO
Most likely cause
Treatment
ECG ndash filed unsigned and
unseen
Emergency Department HMO education series
2012
Diagnosis
Acute cardiac failure ndash APO
Most likely cause
Treatment
Emergency Department HMO education series
2012
Diagnosis - APO
Acute cardiac failure
Treatment
Medications Nitroglycerin SL topical or IV titrated to avoid hypotension Most rapidly
venodilates reduces LV afterload and corrects myocardial ischaemia
Frusemide IV Despite universal use absolute efficacy is unclear
Ventilatory Assistance Non-invasive ventilation (NIV) reduces mortality by 40 particularly with CPAP
and reduces need to intubate
Emergency Department HMO education series
2012
Case C2 - Male in 60rsquos
Progressive SOB over 6 months worse over 24 hours
Orthopnoea Paroxysmal nocturnal dyspnoea (PND) SOA All present to a minor degree over the 6 months but worse for 24 hours
Palpitations (last 24 hours)
Previous AMI 4 years ago pace maker
Ex-smoker Hypertension (HT) diabetes
Emergency Department HMO education series
2012
Examination
Unwell looking with increased work of breathing
RR 26 afeb HR Irreg 130 BP 10070
Sat 90 RA
JVP 5cm
SOA ++
Displaced apex beat no cardiac murmurs 3rd heart sound present
Normal chest expansion but stony dull percussion in the bases (RgtL) bilateral inspiratory crepitations just above the dull areas
ECG ndash what is your diagnosis
Emergency Department HMO education series
2012
Cardiac failure
Emergency Department HMO education series
2012
Case C2 - Summary
Long standing heart failure with an acute
exacerbation due to new onset rapid AF
Treatment of AF amp heart failure
Antithrombotic strategy
Then rate control
Perhaps rhythm control
See review article re AF treatment
To be published early 2013 Australian Rural Doctor
Case D
Mid 60s male
Found SOB ++ in street
Ambulance called
In ED
SOB at rest
Doesnt want help
Funny smell
Further information
Dishevelled
HR 120 reg BP 9560 Sats 94 RA
Vomiting intermittently
What will you do
Further treatment and
investigation
Further history from patient and collateral
sources
Resuscitation
IV access fluids
Bloods ndash FBC UEC CMP Blood gas
pH 71 pCO2 20 pO2 90 HCO3 10 BE -16
Further treatment and
investigation
Further history from patient and collateral
sources
Resuscitation
IV access fluids
Bloods ndash FBC UEC CMP Blood gas
pH 71 pCO2 20 pO2 90 HCO3 10 BE -16
BSL gt30
Further treatment and
investigation
Treatment
IV fluids ndash caution with Na and cerebral oedema
IV insulin
001 ndash 01 unitskghr
aim for BSL 2mmolL drop per hour
Continue until metabolic correction
Monitor and correct K+ other electrolytes
Monitor urine ketones VBGABG
Identify precipitant
Resolution
Wife arrives and is relieved to find husband
Chairman of Rotary Club
UTI developed whilst wife away for weekend
Questions
Summary
Diagnosis of the breathless patient requires you to look for clueshellip The time course of the illness
Associated symptoms
Known diseases or risk factors for disease
Treatment of illnesses supported by evidence for pneumonia asthma PE AF etc
Interpretation of radiology best done with clinical context
Thankyou
Emergency Department HMO education series
2012
What else should I ask
Travel historyhellip
Other important symptoms of respiratory
disease
Cough
Acute
Chronic
Haemoptysis (cancer TB other infections)
Chest Pain
Daytime sleepiness (obstructive sleep apnea)
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Notes for next time
Slide 43 onwards ndash clean up regarding the
XRs confusing in lecture
PE ndash ECG discussion
Learning objectives
Explore familiar material (mostly)
Diagnostic reasoning
Be able to describe the differences and similarities in the medical history
physical examination and investigations of common or life threatening
causes of dyspnoea
Pre reading
Hughes T amp Cruickshank J Adult Emergency Medicine at a Glance
Chichester West Sussex UK John Wiley amp Sons 2011 Chapter 36 -
Shortness of breath Chapter 7 - Blood gas analysis
Refer to ED lecture series and self directed
workbooks
Learning resources
httpwwwrchorgauclinicalguide
httpwwwmdcalccomwells-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 17135(2)98-107 httpwwwncbinlmnihgovpubmed11453709
Written asthma action plans httpwwwnationalasthmaorgaumanaging-
asthmacontrolling-your-asthmawritten-asthma-action-plans
Pneumonia severity scoring systems for community-acquired pneumonia in adults
(Appendix 24) httpjaspertgcomaucompletetgcabg8052htm
httplifeinthefastlanecom200911a-classic-respiratory-case
Emergency Department HMO education series
2012
Dyspnoea ndash The lsquowork uprsquo
History
Cardinal features
Associated features
Risk factors (for diseases) past history (known
diseases) respiratory reserve ldquowhat can the patient
do usuallyrdquo
Examination findings
Inspection Palpation Percussion Auscultation
Suitabletargeted investigations
CXR ECG ABGrsquos basic bloods
CTCTPA VQ Lung function exercise test echo
Emergency Department HMO education series
2013
Diagnosis and severity
SOB + associated symptoms = cause or differential diagnosis
SOB + stridor = Inspiratory obstruction eg croup FB
SOB + Pleuritic pain = PE Pneumonia pneumothorax
SOB + wheeze = Asthma COPD lsquocardiac asthmarsquo or APO
SOB + fevercoughsputum = Pneumonia other infection APO
SOB + haemoptysis = Upper airway lesion pneumonia PE cancer
vasculitis
The severity of symptoms
Current distress
Breathless at rest talking on exertion
Oxygen needs
O2 sats oxygen flow and delivery system
Rate of onset and subsequent lsquotrendrsquo
Previous experience of patient (ITU admissions)
Diagnosis and severity
Background history
Expanding on the detail for a differential diagnosis eg
PE - recent travel FHx Wellrsquos criteria PERC score
Eliciting the history for therapeutic guidance
Pneumonia - CURB-65 hospital vs community acquired
immunosuppression contacts incl animals and birds known
recent outbreaks eg Legionella
Ask about
Medications including doses compliance recent changes
Who normally looks after the patient and where
good summary of recent treatment Think the GP specialist
clinic letters recent admissionsdischarge summaries
Emergency Department HMO education series
2012
Paediatrics
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 only observation
The Royal Childrenrsquos clinical guidelines are an excellent
resource to look up while working in the Emergency
Department
httpwwwuhsnhsukMediasuhtidealTopNavigationArticlesSkil
lsForPracticeClinicalSkillspaediatricassessmentpdf
Emergency Department HMO education series
2013
Paediatrics
Cases
Emergency Department HMO education series
2013
Case A
2 yo presents to ED at 2200 with mother
Not distressed (child ndash mother anxious)
Stridor noted at triage
What is your differential
Emergency Department HMO education series
2013
What is your differential
Croup
FB
Epiglottitis
Upper airway massswelling
Functional
Emergency Department HMO education series
2013
Emergency Department HMO education series
2012
What else might you elicit in
the history
What else might you elicit in
the history Recent or current viral illness in child sibs or
kinderchild care
Similar events in the past
Immunisation history (How many doses of Hib and when)
Fluids and food intake
How parentcarer feels about behavior
Possible FB
Emergency Department HMO education series
2013
On review
Child becomes distressed when you
approach and attempt to examine
Remember
Emergency Department HMO education series
2013
Emergency Department HMO education series
2012
On review
Child becomes distressed when you
approach and attempt to examine
Emergency Department HMO education series
2012
On review
Child becomes distressed when you
approach and attempt to examine
St Gurnasty Infirmary Unpleasantshire Hospitals
Services Trust
Kill or be killed
On review
Child becomes distressed when you
approach and attempt to examine
Intercostal recession marked
Tracheal tug noted
Also note respiratory rate O2 requirements
Emergency Department HMO education series
2013
text
Croup
Emergency Department HMO education series
2013
Treatment
Steroids have been shown to decrease the length of hospital stay need for nebulised Adrenaline and
other interventions
Mild to Moderate Croup
Prednisolone 1mgkg AND prescribe a second dose for the next evening OR a single dose of
Oral Dexamethasone 015mgkg Observe for half an hour post steroid administration Discharge
once stridor-free at rest
Severe croup
Nebulised adrenaline (1 mL of 1 adrenaline diluted to 4 ml with Normal Saline or 5ml of adrenaline
11000)
AND
Give 06mgkg (max 12mg) IMIV dexamethasone
Emergency Department HMO education series
2013
Case B
22 yo man
Brought to the ED by his partner
Sudden onset of SOB
Now present for few hours
How is your differential diagnosis affected by
the sudden onset
Emergency Department HMO education series
2013
Further history
Previously well smokes 10 cigarettesday
Left sided chest pain
Moderate
Pleuritic
Started with the SOB
Is there anything else you would like to ask
What is your differential diagnosis
Emergency Department HMO education series
2013
Emergency Department HMO education series
2012
Differential diagnosis
Pneumothorax
Arrhythmia
Pulmonary Embolism
Asthma (less likely)
Pneumonia
Anxiety
Emergency Department HMO education series
2012
Differential diagnosis
Pneumothorax
Arrhythmia
Pulmonary Embolism
Asthma (less likely)
Pneumonia
Anxiety (Imagine that being your diagnosis and you missed a pound$^ your honour)
You horrible
little doctor
Emergency Department HMO education series
2012
Examination findings
Looks unwell quite distressed with WOB
RR 26 HR 125 SR BP 8060 afebrile
Saturation 93 RA (room air)
Trachea midline
chest expansion on the left
Hyper-resonant percussion note on the left
air entry left lung
What is going on
Is this serious
What is your immediate management
Emergency Department HMO education series
2012
Describe this CXR
Emergency Department HMO education series
2012
Describe this CXR
gt or lt 2cm
Where gt 2cm then pneumothorax is gt50 and is considered large
Emergency Department HMO education series
2012
Describe this CXR
Bigger image next slide
Tethered
lung
gt2cm
Right shift of
mediastinum
Air next to
pericardium
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)
Tension
bullLarge bore cannula 2nd intercostal space mid-clavicular line
If large non-tension
bullgt2cm rim (ie gt50)
bull14-18 G cannula safe triangle (or 2ICS if contraindicated) - aspirate
bullDrain 8-14 FG is usually adequate although 28 FG may be required with
mechanical ventilation
Other considerations
bullNo improvement with drain ndash suction cardiothoracic involvement
httpthoraxbmjcomcontent58suppl_2ii39full
httpssecurecollemergencymedacukcodedocumentaspID=6194
Describe the treatment for
Pneumothorax
httpwwwbrit-thoracicorgukPortals0GuidelinesPleuralDiseaseGuidelinesPleural20Guideline202010Pleural20disease20201020pneumothoraxpdf
Emergency Department HMO education series
2012
Case B2
22 yo 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
Emergency Department HMO education series
2012
Further history amp 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
11070
Sat 97 RA
Widespread wheeze
(what causes this
sound)
Emergency Department HMO education series
2012
Investigations
If the CXR is normal (ish)hellip
Peak Flow 250min (how does this help us)
ABG on room air pH 75 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
Emergency Department HMO education series
2012
Investigations
If the CXR is normalhellip
Peak Flow 250min (how does this help us)
ABG on room air pH 75 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
Emergency Department HMO education series
2012
BBH Asthma protocol
Emergency Department HMO education series
2012
Investigations
If the CXR is normalhellip
Peak Flow 250min (how does this help us)
ABG on room air pH 75 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
Emergency Department HMO education series
2012
Investigations
If the CXR is normalhellip
Peak Flow 300min (how does this help us)
ABG on room air pH 75 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
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 httpwwwnationalasthmaorgauhealth-professionalstools-for-primary-careasthma-action-plansasthma-action-
plan-library
Asthma sticker
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 httpwwwnationalasthmaorgauhealth-professionalstools-for-primary-careasthma-action-plansasthma-action-plan-
library
Discharge checklist
Follow up referral letter to GP
Copy of letter with patient (optional)
Current asthma action plan
Triggers identified
Medications prescribed including
Relievers-short acting B agonists
Preventers-steroids
Symptom controllers-long acting B agonists (if prescribed)
Ensure medications will last until arranged review
Spacer or other delivery systems available and patient
understands use and care
Asthma handouts given (patient information fact sheet)
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 httpwwwnationalasthmaorgauhealth-professionalstools-for-primary-careasthma-action-plansasthma-action-
plan-library
Example action plan
Emergency Department HMO education series
2012
Case B3
22 yo man
Brought to the ED by his partner
Gradual onset of SOB
Now present for few hours
What else do you want to know
Emergency Department HMO education series
2012
Further history amp examination
No wheeze
Productive cough
No recent URTI
Childhood asthma (age
3-12) hay fever
No cardiac history
No risk factors for PE
RR 34 HR 110 SR BP
8965
Sat 87 RA
Dull R base with coarse
crackles
Emergency Department HMO education series
2012
Investigations
The CXR is hellip
ABG on room air
pH 730 CO2 55
O2 70 HCO3 18
What do the blood gases
show
How severe is the
problem
Emergency Department HMO education series
2012
What scoring tools for
pneumonia
SMARTCOP CURB-65 Sepsis guidelines
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
SMARTCOP
SMARTCOP
SMARTCOP
CURB 65
Various website and apps can assist you in
remembering them wwwmdcalccom
Emergency Department HMO education series
2012
Case B4 - Female in her 60rsquos
Sudden onset SOB (present now for 1 hour quite
severe) right sided pleuritic chest pain
Mild fever
Right total knee replacement 3 days ago
persistent leg swelling since yesterday
Non-smoker
No previous cardiorespiratory disease
Emergency Department HMO education series
2012
What is the differential
diagnosis
Emergency Department HMO education series
2012
What is the differential
diagnosis
Most likely
PE
Next likely
Pneumonia
Less likely
Pneumothorax
Arrhythmia
AMI
Emergency Department HMO education series
2012
On examination amp tests
Tachypnoea and some WOB
RR 24 T 376 HR 110 BP 11070
Sats 93 RA
Chest clear with normal percussion and normal breath
sounds
CXR normal
ABG pH 75 CO2 30mmHg p02 62mmHg on RA
Most likely diagnosis
What are Wells criteria
What are Wells criteria
PERC
D-Dimer
What test do you want to do
Emergency Department HMO education series
2012
What can you see
Emergency Department HMO education series
2012
Filling defect R main pulmonary trunk
Emergency Department HMO education series
2012
Emergency Department HMO education series
2012
Case C Man in 60rsquos
Woke this am very SOB and distressed ndash called
ambulance
Progressive SOB over 6 months
Chronic cough
Usually with white sputum
Now worse with no change in sputum colour
No associated fever
SOB in night ndash gets up
Ankles swollen recently
Heavy smoker (35 pack years)
Admission to local hospital 612 ago with chest pains
Emergency Department HMO education series
2012
Differential diagnosis
CCF with acute exacerbation
Chronic obstructive pulmonary disease
(COPD) with acute infective exacerbation
Anaemia
Emergency Department HMO education series
2012
Exam amp investigationshellip
Unwell RR 36 T 368 HR 90 SR BP 180102
Satrsquos 88 RA
Evidence of work of breathing and use of accessory muscles (which are these)
Pursed lip breathing
Prolonged expiration with wheeze
ABG pH 728 pCO2 60 pO2 55 HCO3 26
What do these show
Do you want a CXR
Emergency Department HMO education series
2012
Emergency Department HMO education series
2012
Diagnosis
Acute cardiac failure ndash APO
Most likely cause
Treatment
ECG ndash filed unsigned and
unseen
Emergency Department HMO education series
2012
Diagnosis
Acute cardiac failure ndash APO
Most likely cause
Treatment
Emergency Department HMO education series
2012
Diagnosis - APO
Acute cardiac failure
Treatment
Medications Nitroglycerin SL topical or IV titrated to avoid hypotension Most rapidly
venodilates reduces LV afterload and corrects myocardial ischaemia
Frusemide IV Despite universal use absolute efficacy is unclear
Ventilatory Assistance Non-invasive ventilation (NIV) reduces mortality by 40 particularly with CPAP
and reduces need to intubate
Emergency Department HMO education series
2012
Case C2 - Male in 60rsquos
Progressive SOB over 6 months worse over 24 hours
Orthopnoea Paroxysmal nocturnal dyspnoea (PND) SOA All present to a minor degree over the 6 months but worse for 24 hours
Palpitations (last 24 hours)
Previous AMI 4 years ago pace maker
Ex-smoker Hypertension (HT) diabetes
Emergency Department HMO education series
2012
Examination
Unwell looking with increased work of breathing
RR 26 afeb HR Irreg 130 BP 10070
Sat 90 RA
JVP 5cm
SOA ++
Displaced apex beat no cardiac murmurs 3rd heart sound present
Normal chest expansion but stony dull percussion in the bases (RgtL) bilateral inspiratory crepitations just above the dull areas
ECG ndash what is your diagnosis
Emergency Department HMO education series
2012
Cardiac failure
Emergency Department HMO education series
2012
Case C2 - Summary
Long standing heart failure with an acute
exacerbation due to new onset rapid AF
Treatment of AF amp heart failure
Antithrombotic strategy
Then rate control
Perhaps rhythm control
See review article re AF treatment
To be published early 2013 Australian Rural Doctor
Case D
Mid 60s male
Found SOB ++ in street
Ambulance called
In ED
SOB at rest
Doesnt want help
Funny smell
Further information
Dishevelled
HR 120 reg BP 9560 Sats 94 RA
Vomiting intermittently
What will you do
Further treatment and
investigation
Further history from patient and collateral
sources
Resuscitation
IV access fluids
Bloods ndash FBC UEC CMP Blood gas
pH 71 pCO2 20 pO2 90 HCO3 10 BE -16
Further treatment and
investigation
Further history from patient and collateral
sources
Resuscitation
IV access fluids
Bloods ndash FBC UEC CMP Blood gas
pH 71 pCO2 20 pO2 90 HCO3 10 BE -16
BSL gt30
Further treatment and
investigation
Treatment
IV fluids ndash caution with Na and cerebral oedema
IV insulin
001 ndash 01 unitskghr
aim for BSL 2mmolL drop per hour
Continue until metabolic correction
Monitor and correct K+ other electrolytes
Monitor urine ketones VBGABG
Identify precipitant
Resolution
Wife arrives and is relieved to find husband
Chairman of Rotary Club
UTI developed whilst wife away for weekend
Questions
Summary
Diagnosis of the breathless patient requires you to look for clueshellip The time course of the illness
Associated symptoms
Known diseases or risk factors for disease
Treatment of illnesses supported by evidence for pneumonia asthma PE AF etc
Interpretation of radiology best done with clinical context
Thankyou
Emergency Department HMO education series
2012
What else should I ask
Travel historyhellip
Other important symptoms of respiratory
disease
Cough
Acute
Chronic
Haemoptysis (cancer TB other infections)
Chest Pain
Daytime sleepiness (obstructive sleep apnea)
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Learning objectives
Explore familiar material (mostly)
Diagnostic reasoning
Be able to describe the differences and similarities in the medical history
physical examination and investigations of common or life threatening
causes of dyspnoea
Pre reading
Hughes T amp Cruickshank J Adult Emergency Medicine at a Glance
Chichester West Sussex UK John Wiley amp Sons 2011 Chapter 36 -
Shortness of breath Chapter 7 - Blood gas analysis
Refer to ED lecture series and self directed
workbooks
Learning resources
httpwwwrchorgauclinicalguide
httpwwwmdcalccomwells-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 17135(2)98-107 httpwwwncbinlmnihgovpubmed11453709
Written asthma action plans httpwwwnationalasthmaorgaumanaging-
asthmacontrolling-your-asthmawritten-asthma-action-plans
Pneumonia severity scoring systems for community-acquired pneumonia in adults
(Appendix 24) httpjaspertgcomaucompletetgcabg8052htm
httplifeinthefastlanecom200911a-classic-respiratory-case
Emergency Department HMO education series
2012
Dyspnoea ndash The lsquowork uprsquo
History
Cardinal features
Associated features
Risk factors (for diseases) past history (known
diseases) respiratory reserve ldquowhat can the patient
do usuallyrdquo
Examination findings
Inspection Palpation Percussion Auscultation
Suitabletargeted investigations
CXR ECG ABGrsquos basic bloods
CTCTPA VQ Lung function exercise test echo
Emergency Department HMO education series
2013
Diagnosis and severity
SOB + associated symptoms = cause or differential diagnosis
SOB + stridor = Inspiratory obstruction eg croup FB
SOB + Pleuritic pain = PE Pneumonia pneumothorax
SOB + wheeze = Asthma COPD lsquocardiac asthmarsquo or APO
SOB + fevercoughsputum = Pneumonia other infection APO
SOB + haemoptysis = Upper airway lesion pneumonia PE cancer
vasculitis
The severity of symptoms
Current distress
Breathless at rest talking on exertion
Oxygen needs
O2 sats oxygen flow and delivery system
Rate of onset and subsequent lsquotrendrsquo
Previous experience of patient (ITU admissions)
Diagnosis and severity
Background history
Expanding on the detail for a differential diagnosis eg
PE - recent travel FHx Wellrsquos criteria PERC score
Eliciting the history for therapeutic guidance
Pneumonia - CURB-65 hospital vs community acquired
immunosuppression contacts incl animals and birds known
recent outbreaks eg Legionella
Ask about
Medications including doses compliance recent changes
Who normally looks after the patient and where
good summary of recent treatment Think the GP specialist
clinic letters recent admissionsdischarge summaries
Emergency Department HMO education series
2012
Paediatrics
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 only observation
The Royal Childrenrsquos clinical guidelines are an excellent
resource to look up while working in the Emergency
Department
httpwwwuhsnhsukMediasuhtidealTopNavigationArticlesSkil
lsForPracticeClinicalSkillspaediatricassessmentpdf
Emergency Department HMO education series
2013
Paediatrics
Cases
Emergency Department HMO education series
2013
Case A
2 yo presents to ED at 2200 with mother
Not distressed (child ndash mother anxious)
Stridor noted at triage
What is your differential
Emergency Department HMO education series
2013
What is your differential
Croup
FB
Epiglottitis
Upper airway massswelling
Functional
Emergency Department HMO education series
2013
Emergency Department HMO education series
2012
What else might you elicit in
the history
What else might you elicit in
the history Recent or current viral illness in child sibs or
kinderchild care
Similar events in the past
Immunisation history (How many doses of Hib and when)
Fluids and food intake
How parentcarer feels about behavior
Possible FB
Emergency Department HMO education series
2013
On review
Child becomes distressed when you
approach and attempt to examine
Remember
Emergency Department HMO education series
2013
Emergency Department HMO education series
2012
On review
Child becomes distressed when you
approach and attempt to examine
Emergency Department HMO education series
2012
On review
Child becomes distressed when you
approach and attempt to examine
St Gurnasty Infirmary Unpleasantshire Hospitals
Services Trust
Kill or be killed
On review
Child becomes distressed when you
approach and attempt to examine
Intercostal recession marked
Tracheal tug noted
Also note respiratory rate O2 requirements
Emergency Department HMO education series
2013
text
Croup
Emergency Department HMO education series
2013
Treatment
Steroids have been shown to decrease the length of hospital stay need for nebulised Adrenaline and
other interventions
Mild to Moderate Croup
Prednisolone 1mgkg AND prescribe a second dose for the next evening OR a single dose of
Oral Dexamethasone 015mgkg Observe for half an hour post steroid administration Discharge
once stridor-free at rest
Severe croup
Nebulised adrenaline (1 mL of 1 adrenaline diluted to 4 ml with Normal Saline or 5ml of adrenaline
11000)
AND
Give 06mgkg (max 12mg) IMIV dexamethasone
Emergency Department HMO education series
2013
Case B
22 yo man
Brought to the ED by his partner
Sudden onset of SOB
Now present for few hours
How is your differential diagnosis affected by
the sudden onset
Emergency Department HMO education series
2013
Further history
Previously well smokes 10 cigarettesday
Left sided chest pain
Moderate
Pleuritic
Started with the SOB
Is there anything else you would like to ask
What is your differential diagnosis
Emergency Department HMO education series
2013
Emergency Department HMO education series
2012
Differential diagnosis
Pneumothorax
Arrhythmia
Pulmonary Embolism
Asthma (less likely)
Pneumonia
Anxiety
Emergency Department HMO education series
2012
Differential diagnosis
Pneumothorax
Arrhythmia
Pulmonary Embolism
Asthma (less likely)
Pneumonia
Anxiety (Imagine that being your diagnosis and you missed a pound$^ your honour)
You horrible
little doctor
Emergency Department HMO education series
2012
Examination findings
Looks unwell quite distressed with WOB
RR 26 HR 125 SR BP 8060 afebrile
Saturation 93 RA (room air)
Trachea midline
chest expansion on the left
Hyper-resonant percussion note on the left
air entry left lung
What is going on
Is this serious
What is your immediate management
Emergency Department HMO education series
2012
Describe this CXR
Emergency Department HMO education series
2012
Describe this CXR
gt or lt 2cm
Where gt 2cm then pneumothorax is gt50 and is considered large
Emergency Department HMO education series
2012
Describe this CXR
Bigger image next slide
Tethered
lung
gt2cm
Right shift of
mediastinum
Air next to
pericardium
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)
Tension
bullLarge bore cannula 2nd intercostal space mid-clavicular line
If large non-tension
bullgt2cm rim (ie gt50)
bull14-18 G cannula safe triangle (or 2ICS if contraindicated) - aspirate
bullDrain 8-14 FG is usually adequate although 28 FG may be required with
mechanical ventilation
Other considerations
bullNo improvement with drain ndash suction cardiothoracic involvement
httpthoraxbmjcomcontent58suppl_2ii39full
httpssecurecollemergencymedacukcodedocumentaspID=6194
Describe the treatment for
Pneumothorax
httpwwwbrit-thoracicorgukPortals0GuidelinesPleuralDiseaseGuidelinesPleural20Guideline202010Pleural20disease20201020pneumothoraxpdf
Emergency Department HMO education series
2012
Case B2
22 yo 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
Emergency Department HMO education series
2012
Further history amp 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
11070
Sat 97 RA
Widespread wheeze
(what causes this
sound)
Emergency Department HMO education series
2012
Investigations
If the CXR is normal (ish)hellip
Peak Flow 250min (how does this help us)
ABG on room air pH 75 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
Emergency Department HMO education series
2012
Investigations
If the CXR is normalhellip
Peak Flow 250min (how does this help us)
ABG on room air pH 75 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
Emergency Department HMO education series
2012
BBH Asthma protocol
Emergency Department HMO education series
2012
Investigations
If the CXR is normalhellip
Peak Flow 250min (how does this help us)
ABG on room air pH 75 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
Emergency Department HMO education series
2012
Investigations
If the CXR is normalhellip
Peak Flow 300min (how does this help us)
ABG on room air pH 75 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
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 httpwwwnationalasthmaorgauhealth-professionalstools-for-primary-careasthma-action-plansasthma-action-
plan-library
Asthma sticker
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 httpwwwnationalasthmaorgauhealth-professionalstools-for-primary-careasthma-action-plansasthma-action-plan-
library
Discharge checklist
Follow up referral letter to GP
Copy of letter with patient (optional)
Current asthma action plan
Triggers identified
Medications prescribed including
Relievers-short acting B agonists
Preventers-steroids
Symptom controllers-long acting B agonists (if prescribed)
Ensure medications will last until arranged review
Spacer or other delivery systems available and patient
understands use and care
Asthma handouts given (patient information fact sheet)
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 httpwwwnationalasthmaorgauhealth-professionalstools-for-primary-careasthma-action-plansasthma-action-
plan-library
Example action plan
Emergency Department HMO education series
2012
Case B3
22 yo man
Brought to the ED by his partner
Gradual onset of SOB
Now present for few hours
What else do you want to know
Emergency Department HMO education series
2012
Further history amp examination
No wheeze
Productive cough
No recent URTI
Childhood asthma (age
3-12) hay fever
No cardiac history
No risk factors for PE
RR 34 HR 110 SR BP
8965
Sat 87 RA
Dull R base with coarse
crackles
Emergency Department HMO education series
2012
Investigations
The CXR is hellip
ABG on room air
pH 730 CO2 55
O2 70 HCO3 18
What do the blood gases
show
How severe is the
problem
Emergency Department HMO education series
2012
What scoring tools for
pneumonia
SMARTCOP CURB-65 Sepsis guidelines
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
SMARTCOP
SMARTCOP
SMARTCOP
CURB 65
Various website and apps can assist you in
remembering them wwwmdcalccom
Emergency Department HMO education series
2012
Case B4 - Female in her 60rsquos
Sudden onset SOB (present now for 1 hour quite
severe) right sided pleuritic chest pain
Mild fever
Right total knee replacement 3 days ago
persistent leg swelling since yesterday
Non-smoker
No previous cardiorespiratory disease
Emergency Department HMO education series
2012
What is the differential
diagnosis
Emergency Department HMO education series
2012
What is the differential
diagnosis
Most likely
PE
Next likely
Pneumonia
Less likely
Pneumothorax
Arrhythmia
AMI
Emergency Department HMO education series
2012
On examination amp tests
Tachypnoea and some WOB
RR 24 T 376 HR 110 BP 11070
Sats 93 RA
Chest clear with normal percussion and normal breath
sounds
CXR normal
ABG pH 75 CO2 30mmHg p02 62mmHg on RA
Most likely diagnosis
What are Wells criteria
What are Wells criteria
PERC
D-Dimer
What test do you want to do
Emergency Department HMO education series
2012
What can you see
Emergency Department HMO education series
2012
Filling defect R main pulmonary trunk
Emergency Department HMO education series
2012
Emergency Department HMO education series
2012
Case C Man in 60rsquos
Woke this am very SOB and distressed ndash called
ambulance
Progressive SOB over 6 months
Chronic cough
Usually with white sputum
Now worse with no change in sputum colour
No associated fever
SOB in night ndash gets up
Ankles swollen recently
Heavy smoker (35 pack years)
Admission to local hospital 612 ago with chest pains
Emergency Department HMO education series
2012
Differential diagnosis
CCF with acute exacerbation
Chronic obstructive pulmonary disease
(COPD) with acute infective exacerbation
Anaemia
Emergency Department HMO education series
2012
Exam amp investigationshellip
Unwell RR 36 T 368 HR 90 SR BP 180102
Satrsquos 88 RA
Evidence of work of breathing and use of accessory muscles (which are these)
Pursed lip breathing
Prolonged expiration with wheeze
ABG pH 728 pCO2 60 pO2 55 HCO3 26
What do these show
Do you want a CXR
Emergency Department HMO education series
2012
Emergency Department HMO education series
2012
Diagnosis
Acute cardiac failure ndash APO
Most likely cause
Treatment
ECG ndash filed unsigned and
unseen
Emergency Department HMO education series
2012
Diagnosis
Acute cardiac failure ndash APO
Most likely cause
Treatment
Emergency Department HMO education series
2012
Diagnosis - APO
Acute cardiac failure
Treatment
Medications Nitroglycerin SL topical or IV titrated to avoid hypotension Most rapidly
venodilates reduces LV afterload and corrects myocardial ischaemia
Frusemide IV Despite universal use absolute efficacy is unclear
Ventilatory Assistance Non-invasive ventilation (NIV) reduces mortality by 40 particularly with CPAP
and reduces need to intubate
Emergency Department HMO education series
2012
Case C2 - Male in 60rsquos
Progressive SOB over 6 months worse over 24 hours
Orthopnoea Paroxysmal nocturnal dyspnoea (PND) SOA All present to a minor degree over the 6 months but worse for 24 hours
Palpitations (last 24 hours)
Previous AMI 4 years ago pace maker
Ex-smoker Hypertension (HT) diabetes
Emergency Department HMO education series
2012
Examination
Unwell looking with increased work of breathing
RR 26 afeb HR Irreg 130 BP 10070
Sat 90 RA
JVP 5cm
SOA ++
Displaced apex beat no cardiac murmurs 3rd heart sound present
Normal chest expansion but stony dull percussion in the bases (RgtL) bilateral inspiratory crepitations just above the dull areas
ECG ndash what is your diagnosis
Emergency Department HMO education series
2012
Cardiac failure
Emergency Department HMO education series
2012
Case C2 - Summary
Long standing heart failure with an acute
exacerbation due to new onset rapid AF
Treatment of AF amp heart failure
Antithrombotic strategy
Then rate control
Perhaps rhythm control
See review article re AF treatment
To be published early 2013 Australian Rural Doctor
Case D
Mid 60s male
Found SOB ++ in street
Ambulance called
In ED
SOB at rest
Doesnt want help
Funny smell
Further information
Dishevelled
HR 120 reg BP 9560 Sats 94 RA
Vomiting intermittently
What will you do
Further treatment and
investigation
Further history from patient and collateral
sources
Resuscitation
IV access fluids
Bloods ndash FBC UEC CMP Blood gas
pH 71 pCO2 20 pO2 90 HCO3 10 BE -16
Further treatment and
investigation
Further history from patient and collateral
sources
Resuscitation
IV access fluids
Bloods ndash FBC UEC CMP Blood gas
pH 71 pCO2 20 pO2 90 HCO3 10 BE -16
BSL gt30
Further treatment and
investigation
Treatment
IV fluids ndash caution with Na and cerebral oedema
IV insulin
001 ndash 01 unitskghr
aim for BSL 2mmolL drop per hour
Continue until metabolic correction
Monitor and correct K+ other electrolytes
Monitor urine ketones VBGABG
Identify precipitant
Resolution
Wife arrives and is relieved to find husband
Chairman of Rotary Club
UTI developed whilst wife away for weekend
Questions
Summary
Diagnosis of the breathless patient requires you to look for clueshellip The time course of the illness
Associated symptoms
Known diseases or risk factors for disease
Treatment of illnesses supported by evidence for pneumonia asthma PE AF etc
Interpretation of radiology best done with clinical context
Thankyou
Emergency Department HMO education series
2012
What else should I ask
Travel historyhellip
Other important symptoms of respiratory
disease
Cough
Acute
Chronic
Haemoptysis (cancer TB other infections)
Chest Pain
Daytime sleepiness (obstructive sleep apnea)
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Learning resources
httpwwwrchorgauclinicalguide
httpwwwmdcalccomwells-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 17135(2)98-107 httpwwwncbinlmnihgovpubmed11453709
Written asthma action plans httpwwwnationalasthmaorgaumanaging-
asthmacontrolling-your-asthmawritten-asthma-action-plans
Pneumonia severity scoring systems for community-acquired pneumonia in adults
(Appendix 24) httpjaspertgcomaucompletetgcabg8052htm
httplifeinthefastlanecom200911a-classic-respiratory-case
Emergency Department HMO education series
2012
Dyspnoea ndash The lsquowork uprsquo
History
Cardinal features
Associated features
Risk factors (for diseases) past history (known
diseases) respiratory reserve ldquowhat can the patient
do usuallyrdquo
Examination findings
Inspection Palpation Percussion Auscultation
Suitabletargeted investigations
CXR ECG ABGrsquos basic bloods
CTCTPA VQ Lung function exercise test echo
Emergency Department HMO education series
2013
Diagnosis and severity
SOB + associated symptoms = cause or differential diagnosis
SOB + stridor = Inspiratory obstruction eg croup FB
SOB + Pleuritic pain = PE Pneumonia pneumothorax
SOB + wheeze = Asthma COPD lsquocardiac asthmarsquo or APO
SOB + fevercoughsputum = Pneumonia other infection APO
SOB + haemoptysis = Upper airway lesion pneumonia PE cancer
vasculitis
The severity of symptoms
Current distress
Breathless at rest talking on exertion
Oxygen needs
O2 sats oxygen flow and delivery system
Rate of onset and subsequent lsquotrendrsquo
Previous experience of patient (ITU admissions)
Diagnosis and severity
Background history
Expanding on the detail for a differential diagnosis eg
PE - recent travel FHx Wellrsquos criteria PERC score
Eliciting the history for therapeutic guidance
Pneumonia - CURB-65 hospital vs community acquired
immunosuppression contacts incl animals and birds known
recent outbreaks eg Legionella
Ask about
Medications including doses compliance recent changes
Who normally looks after the patient and where
good summary of recent treatment Think the GP specialist
clinic letters recent admissionsdischarge summaries
Emergency Department HMO education series
2012
Paediatrics
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 only observation
The Royal Childrenrsquos clinical guidelines are an excellent
resource to look up while working in the Emergency
Department
httpwwwuhsnhsukMediasuhtidealTopNavigationArticlesSkil
lsForPracticeClinicalSkillspaediatricassessmentpdf
Emergency Department HMO education series
2013
Paediatrics
Cases
Emergency Department HMO education series
2013
Case A
2 yo presents to ED at 2200 with mother
Not distressed (child ndash mother anxious)
Stridor noted at triage
What is your differential
Emergency Department HMO education series
2013
What is your differential
Croup
FB
Epiglottitis
Upper airway massswelling
Functional
Emergency Department HMO education series
2013
Emergency Department HMO education series
2012
What else might you elicit in
the history
What else might you elicit in
the history Recent or current viral illness in child sibs or
kinderchild care
Similar events in the past
Immunisation history (How many doses of Hib and when)
Fluids and food intake
How parentcarer feels about behavior
Possible FB
Emergency Department HMO education series
2013
On review
Child becomes distressed when you
approach and attempt to examine
Remember
Emergency Department HMO education series
2013
Emergency Department HMO education series
2012
On review
Child becomes distressed when you
approach and attempt to examine
Emergency Department HMO education series
2012
On review
Child becomes distressed when you
approach and attempt to examine
St Gurnasty Infirmary Unpleasantshire Hospitals
Services Trust
Kill or be killed
On review
Child becomes distressed when you
approach and attempt to examine
Intercostal recession marked
Tracheal tug noted
Also note respiratory rate O2 requirements
Emergency Department HMO education series
2013
text
Croup
Emergency Department HMO education series
2013
Treatment
Steroids have been shown to decrease the length of hospital stay need for nebulised Adrenaline and
other interventions
Mild to Moderate Croup
Prednisolone 1mgkg AND prescribe a second dose for the next evening OR a single dose of
Oral Dexamethasone 015mgkg Observe for half an hour post steroid administration Discharge
once stridor-free at rest
Severe croup
Nebulised adrenaline (1 mL of 1 adrenaline diluted to 4 ml with Normal Saline or 5ml of adrenaline
11000)
AND
Give 06mgkg (max 12mg) IMIV dexamethasone
Emergency Department HMO education series
2013
Case B
22 yo man
Brought to the ED by his partner
Sudden onset of SOB
Now present for few hours
How is your differential diagnosis affected by
the sudden onset
Emergency Department HMO education series
2013
Further history
Previously well smokes 10 cigarettesday
Left sided chest pain
Moderate
Pleuritic
Started with the SOB
Is there anything else you would like to ask
What is your differential diagnosis
Emergency Department HMO education series
2013
Emergency Department HMO education series
2012
Differential diagnosis
Pneumothorax
Arrhythmia
Pulmonary Embolism
Asthma (less likely)
Pneumonia
Anxiety
Emergency Department HMO education series
2012
Differential diagnosis
Pneumothorax
Arrhythmia
Pulmonary Embolism
Asthma (less likely)
Pneumonia
Anxiety (Imagine that being your diagnosis and you missed a pound$^ your honour)
You horrible
little doctor
Emergency Department HMO education series
2012
Examination findings
Looks unwell quite distressed with WOB
RR 26 HR 125 SR BP 8060 afebrile
Saturation 93 RA (room air)
Trachea midline
chest expansion on the left
Hyper-resonant percussion note on the left
air entry left lung
What is going on
Is this serious
What is your immediate management
Emergency Department HMO education series
2012
Describe this CXR
Emergency Department HMO education series
2012
Describe this CXR
gt or lt 2cm
Where gt 2cm then pneumothorax is gt50 and is considered large
Emergency Department HMO education series
2012
Describe this CXR
Bigger image next slide
Tethered
lung
gt2cm
Right shift of
mediastinum
Air next to
pericardium
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)
Tension
bullLarge bore cannula 2nd intercostal space mid-clavicular line
If large non-tension
bullgt2cm rim (ie gt50)
bull14-18 G cannula safe triangle (or 2ICS if contraindicated) - aspirate
bullDrain 8-14 FG is usually adequate although 28 FG may be required with
mechanical ventilation
Other considerations
bullNo improvement with drain ndash suction cardiothoracic involvement
httpthoraxbmjcomcontent58suppl_2ii39full
httpssecurecollemergencymedacukcodedocumentaspID=6194
Describe the treatment for
Pneumothorax
httpwwwbrit-thoracicorgukPortals0GuidelinesPleuralDiseaseGuidelinesPleural20Guideline202010Pleural20disease20201020pneumothoraxpdf
Emergency Department HMO education series
2012
Case B2
22 yo 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
Emergency Department HMO education series
2012
Further history amp 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
11070
Sat 97 RA
Widespread wheeze
(what causes this
sound)
Emergency Department HMO education series
2012
Investigations
If the CXR is normal (ish)hellip
Peak Flow 250min (how does this help us)
ABG on room air pH 75 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
Emergency Department HMO education series
2012
Investigations
If the CXR is normalhellip
Peak Flow 250min (how does this help us)
ABG on room air pH 75 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
Emergency Department HMO education series
2012
BBH Asthma protocol
Emergency Department HMO education series
2012
Investigations
If the CXR is normalhellip
Peak Flow 250min (how does this help us)
ABG on room air pH 75 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
Emergency Department HMO education series
2012
Investigations
If the CXR is normalhellip
Peak Flow 300min (how does this help us)
ABG on room air pH 75 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
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 httpwwwnationalasthmaorgauhealth-professionalstools-for-primary-careasthma-action-plansasthma-action-
plan-library
Asthma sticker
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 httpwwwnationalasthmaorgauhealth-professionalstools-for-primary-careasthma-action-plansasthma-action-plan-
library
Discharge checklist
Follow up referral letter to GP
Copy of letter with patient (optional)
Current asthma action plan
Triggers identified
Medications prescribed including
Relievers-short acting B agonists
Preventers-steroids
Symptom controllers-long acting B agonists (if prescribed)
Ensure medications will last until arranged review
Spacer or other delivery systems available and patient
understands use and care
Asthma handouts given (patient information fact sheet)
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 httpwwwnationalasthmaorgauhealth-professionalstools-for-primary-careasthma-action-plansasthma-action-
plan-library
Example action plan
Emergency Department HMO education series
2012
Case B3
22 yo man
Brought to the ED by his partner
Gradual onset of SOB
Now present for few hours
What else do you want to know
Emergency Department HMO education series
2012
Further history amp examination
No wheeze
Productive cough
No recent URTI
Childhood asthma (age
3-12) hay fever
No cardiac history
No risk factors for PE
RR 34 HR 110 SR BP
8965
Sat 87 RA
Dull R base with coarse
crackles
Emergency Department HMO education series
2012
Investigations
The CXR is hellip
ABG on room air
pH 730 CO2 55
O2 70 HCO3 18
What do the blood gases
show
How severe is the
problem
Emergency Department HMO education series
2012
What scoring tools for
pneumonia
SMARTCOP CURB-65 Sepsis guidelines
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
SMARTCOP
SMARTCOP
SMARTCOP
CURB 65
Various website and apps can assist you in
remembering them wwwmdcalccom
Emergency Department HMO education series
2012
Case B4 - Female in her 60rsquos
Sudden onset SOB (present now for 1 hour quite
severe) right sided pleuritic chest pain
Mild fever
Right total knee replacement 3 days ago
persistent leg swelling since yesterday
Non-smoker
No previous cardiorespiratory disease
Emergency Department HMO education series
2012
What is the differential
diagnosis
Emergency Department HMO education series
2012
What is the differential
diagnosis
Most likely
PE
Next likely
Pneumonia
Less likely
Pneumothorax
Arrhythmia
AMI
Emergency Department HMO education series
2012
On examination amp tests
Tachypnoea and some WOB
RR 24 T 376 HR 110 BP 11070
Sats 93 RA
Chest clear with normal percussion and normal breath
sounds
CXR normal
ABG pH 75 CO2 30mmHg p02 62mmHg on RA
Most likely diagnosis
What are Wells criteria
What are Wells criteria
PERC
D-Dimer
What test do you want to do
Emergency Department HMO education series
2012
What can you see
Emergency Department HMO education series
2012
Filling defect R main pulmonary trunk
Emergency Department HMO education series
2012
Emergency Department HMO education series
2012
Case C Man in 60rsquos
Woke this am very SOB and distressed ndash called
ambulance
Progressive SOB over 6 months
Chronic cough
Usually with white sputum
Now worse with no change in sputum colour
No associated fever
SOB in night ndash gets up
Ankles swollen recently
Heavy smoker (35 pack years)
Admission to local hospital 612 ago with chest pains
Emergency Department HMO education series
2012
Differential diagnosis
CCF with acute exacerbation
Chronic obstructive pulmonary disease
(COPD) with acute infective exacerbation
Anaemia
Emergency Department HMO education series
2012
Exam amp investigationshellip
Unwell RR 36 T 368 HR 90 SR BP 180102
Satrsquos 88 RA
Evidence of work of breathing and use of accessory muscles (which are these)
Pursed lip breathing
Prolonged expiration with wheeze
ABG pH 728 pCO2 60 pO2 55 HCO3 26
What do these show
Do you want a CXR
Emergency Department HMO education series
2012
Emergency Department HMO education series
2012
Diagnosis
Acute cardiac failure ndash APO
Most likely cause
Treatment
ECG ndash filed unsigned and
unseen
Emergency Department HMO education series
2012
Diagnosis
Acute cardiac failure ndash APO
Most likely cause
Treatment
Emergency Department HMO education series
2012
Diagnosis - APO
Acute cardiac failure
Treatment
Medications Nitroglycerin SL topical or IV titrated to avoid hypotension Most rapidly
venodilates reduces LV afterload and corrects myocardial ischaemia
Frusemide IV Despite universal use absolute efficacy is unclear
Ventilatory Assistance Non-invasive ventilation (NIV) reduces mortality by 40 particularly with CPAP
and reduces need to intubate
Emergency Department HMO education series
2012
Case C2 - Male in 60rsquos
Progressive SOB over 6 months worse over 24 hours
Orthopnoea Paroxysmal nocturnal dyspnoea (PND) SOA All present to a minor degree over the 6 months but worse for 24 hours
Palpitations (last 24 hours)
Previous AMI 4 years ago pace maker
Ex-smoker Hypertension (HT) diabetes
Emergency Department HMO education series
2012
Examination
Unwell looking with increased work of breathing
RR 26 afeb HR Irreg 130 BP 10070
Sat 90 RA
JVP 5cm
SOA ++
Displaced apex beat no cardiac murmurs 3rd heart sound present
Normal chest expansion but stony dull percussion in the bases (RgtL) bilateral inspiratory crepitations just above the dull areas
ECG ndash what is your diagnosis
Emergency Department HMO education series
2012
Cardiac failure
Emergency Department HMO education series
2012
Case C2 - Summary
Long standing heart failure with an acute
exacerbation due to new onset rapid AF
Treatment of AF amp heart failure
Antithrombotic strategy
Then rate control
Perhaps rhythm control
See review article re AF treatment
To be published early 2013 Australian Rural Doctor
Case D
Mid 60s male
Found SOB ++ in street
Ambulance called
In ED
SOB at rest
Doesnt want help
Funny smell
Further information
Dishevelled
HR 120 reg BP 9560 Sats 94 RA
Vomiting intermittently
What will you do
Further treatment and
investigation
Further history from patient and collateral
sources
Resuscitation
IV access fluids
Bloods ndash FBC UEC CMP Blood gas
pH 71 pCO2 20 pO2 90 HCO3 10 BE -16
Further treatment and
investigation
Further history from patient and collateral
sources
Resuscitation
IV access fluids
Bloods ndash FBC UEC CMP Blood gas
pH 71 pCO2 20 pO2 90 HCO3 10 BE -16
BSL gt30
Further treatment and
investigation
Treatment
IV fluids ndash caution with Na and cerebral oedema
IV insulin
001 ndash 01 unitskghr
aim for BSL 2mmolL drop per hour
Continue until metabolic correction
Monitor and correct K+ other electrolytes
Monitor urine ketones VBGABG
Identify precipitant
Resolution
Wife arrives and is relieved to find husband
Chairman of Rotary Club
UTI developed whilst wife away for weekend
Questions
Summary
Diagnosis of the breathless patient requires you to look for clueshellip The time course of the illness
Associated symptoms
Known diseases or risk factors for disease
Treatment of illnesses supported by evidence for pneumonia asthma PE AF etc
Interpretation of radiology best done with clinical context
Thankyou
Emergency Department HMO education series
2012
What else should I ask
Travel historyhellip
Other important symptoms of respiratory
disease
Cough
Acute
Chronic
Haemoptysis (cancer TB other infections)
Chest Pain
Daytime sleepiness (obstructive sleep apnea)
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Emergency Department HMO education series
2012
Dyspnoea ndash The lsquowork uprsquo
History
Cardinal features
Associated features
Risk factors (for diseases) past history (known
diseases) respiratory reserve ldquowhat can the patient
do usuallyrdquo
Examination findings
Inspection Palpation Percussion Auscultation
Suitabletargeted investigations
CXR ECG ABGrsquos basic bloods
CTCTPA VQ Lung function exercise test echo
Emergency Department HMO education series
2013
Diagnosis and severity
SOB + associated symptoms = cause or differential diagnosis
SOB + stridor = Inspiratory obstruction eg croup FB
SOB + Pleuritic pain = PE Pneumonia pneumothorax
SOB + wheeze = Asthma COPD lsquocardiac asthmarsquo or APO
SOB + fevercoughsputum = Pneumonia other infection APO
SOB + haemoptysis = Upper airway lesion pneumonia PE cancer
vasculitis
The severity of symptoms
Current distress
Breathless at rest talking on exertion
Oxygen needs
O2 sats oxygen flow and delivery system
Rate of onset and subsequent lsquotrendrsquo
Previous experience of patient (ITU admissions)
Diagnosis and severity
Background history
Expanding on the detail for a differential diagnosis eg
PE - recent travel FHx Wellrsquos criteria PERC score
Eliciting the history for therapeutic guidance
Pneumonia - CURB-65 hospital vs community acquired
immunosuppression contacts incl animals and birds known
recent outbreaks eg Legionella
Ask about
Medications including doses compliance recent changes
Who normally looks after the patient and where
good summary of recent treatment Think the GP specialist
clinic letters recent admissionsdischarge summaries
Emergency Department HMO education series
2012
Paediatrics
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 only observation
The Royal Childrenrsquos clinical guidelines are an excellent
resource to look up while working in the Emergency
Department
httpwwwuhsnhsukMediasuhtidealTopNavigationArticlesSkil
lsForPracticeClinicalSkillspaediatricassessmentpdf
Emergency Department HMO education series
2013
Paediatrics
Cases
Emergency Department HMO education series
2013
Case A
2 yo presents to ED at 2200 with mother
Not distressed (child ndash mother anxious)
Stridor noted at triage
What is your differential
Emergency Department HMO education series
2013
What is your differential
Croup
FB
Epiglottitis
Upper airway massswelling
Functional
Emergency Department HMO education series
2013
Emergency Department HMO education series
2012
What else might you elicit in
the history
What else might you elicit in
the history Recent or current viral illness in child sibs or
kinderchild care
Similar events in the past
Immunisation history (How many doses of Hib and when)
Fluids and food intake
How parentcarer feels about behavior
Possible FB
Emergency Department HMO education series
2013
On review
Child becomes distressed when you
approach and attempt to examine
Remember
Emergency Department HMO education series
2013
Emergency Department HMO education series
2012
On review
Child becomes distressed when you
approach and attempt to examine
Emergency Department HMO education series
2012
On review
Child becomes distressed when you
approach and attempt to examine
St Gurnasty Infirmary Unpleasantshire Hospitals
Services Trust
Kill or be killed
On review
Child becomes distressed when you
approach and attempt to examine
Intercostal recession marked
Tracheal tug noted
Also note respiratory rate O2 requirements
Emergency Department HMO education series
2013
text
Croup
Emergency Department HMO education series
2013
Treatment
Steroids have been shown to decrease the length of hospital stay need for nebulised Adrenaline and
other interventions
Mild to Moderate Croup
Prednisolone 1mgkg AND prescribe a second dose for the next evening OR a single dose of
Oral Dexamethasone 015mgkg Observe for half an hour post steroid administration Discharge
once stridor-free at rest
Severe croup
Nebulised adrenaline (1 mL of 1 adrenaline diluted to 4 ml with Normal Saline or 5ml of adrenaline
11000)
AND
Give 06mgkg (max 12mg) IMIV dexamethasone
Emergency Department HMO education series
2013
Case B
22 yo man
Brought to the ED by his partner
Sudden onset of SOB
Now present for few hours
How is your differential diagnosis affected by
the sudden onset
Emergency Department HMO education series
2013
Further history
Previously well smokes 10 cigarettesday
Left sided chest pain
Moderate
Pleuritic
Started with the SOB
Is there anything else you would like to ask
What is your differential diagnosis
Emergency Department HMO education series
2013
Emergency Department HMO education series
2012
Differential diagnosis
Pneumothorax
Arrhythmia
Pulmonary Embolism
Asthma (less likely)
Pneumonia
Anxiety
Emergency Department HMO education series
2012
Differential diagnosis
Pneumothorax
Arrhythmia
Pulmonary Embolism
Asthma (less likely)
Pneumonia
Anxiety (Imagine that being your diagnosis and you missed a pound$^ your honour)
You horrible
little doctor
Emergency Department HMO education series
2012
Examination findings
Looks unwell quite distressed with WOB
RR 26 HR 125 SR BP 8060 afebrile
Saturation 93 RA (room air)
Trachea midline
chest expansion on the left
Hyper-resonant percussion note on the left
air entry left lung
What is going on
Is this serious
What is your immediate management
Emergency Department HMO education series
2012
Describe this CXR
Emergency Department HMO education series
2012
Describe this CXR
gt or lt 2cm
Where gt 2cm then pneumothorax is gt50 and is considered large
Emergency Department HMO education series
2012
Describe this CXR
Bigger image next slide
Tethered
lung
gt2cm
Right shift of
mediastinum
Air next to
pericardium
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)
Tension
bullLarge bore cannula 2nd intercostal space mid-clavicular line
If large non-tension
bullgt2cm rim (ie gt50)
bull14-18 G cannula safe triangle (or 2ICS if contraindicated) - aspirate
bullDrain 8-14 FG is usually adequate although 28 FG may be required with
mechanical ventilation
Other considerations
bullNo improvement with drain ndash suction cardiothoracic involvement
httpthoraxbmjcomcontent58suppl_2ii39full
httpssecurecollemergencymedacukcodedocumentaspID=6194
Describe the treatment for
Pneumothorax
httpwwwbrit-thoracicorgukPortals0GuidelinesPleuralDiseaseGuidelinesPleural20Guideline202010Pleural20disease20201020pneumothoraxpdf
Emergency Department HMO education series
2012
Case B2
22 yo 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
Emergency Department HMO education series
2012
Further history amp 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
11070
Sat 97 RA
Widespread wheeze
(what causes this
sound)
Emergency Department HMO education series
2012
Investigations
If the CXR is normal (ish)hellip
Peak Flow 250min (how does this help us)
ABG on room air pH 75 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
Emergency Department HMO education series
2012
Investigations
If the CXR is normalhellip
Peak Flow 250min (how does this help us)
ABG on room air pH 75 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
Emergency Department HMO education series
2012
BBH Asthma protocol
Emergency Department HMO education series
2012
Investigations
If the CXR is normalhellip
Peak Flow 250min (how does this help us)
ABG on room air pH 75 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
Emergency Department HMO education series
2012
Investigations
If the CXR is normalhellip
Peak Flow 300min (how does this help us)
ABG on room air pH 75 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
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 httpwwwnationalasthmaorgauhealth-professionalstools-for-primary-careasthma-action-plansasthma-action-
plan-library
Asthma sticker
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 httpwwwnationalasthmaorgauhealth-professionalstools-for-primary-careasthma-action-plansasthma-action-plan-
library
Discharge checklist
Follow up referral letter to GP
Copy of letter with patient (optional)
Current asthma action plan
Triggers identified
Medications prescribed including
Relievers-short acting B agonists
Preventers-steroids
Symptom controllers-long acting B agonists (if prescribed)
Ensure medications will last until arranged review
Spacer or other delivery systems available and patient
understands use and care
Asthma handouts given (patient information fact sheet)
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 httpwwwnationalasthmaorgauhealth-professionalstools-for-primary-careasthma-action-plansasthma-action-
plan-library
Example action plan
Emergency Department HMO education series
2012
Case B3
22 yo man
Brought to the ED by his partner
Gradual onset of SOB
Now present for few hours
What else do you want to know
Emergency Department HMO education series
2012
Further history amp examination
No wheeze
Productive cough
No recent URTI
Childhood asthma (age
3-12) hay fever
No cardiac history
No risk factors for PE
RR 34 HR 110 SR BP
8965
Sat 87 RA
Dull R base with coarse
crackles
Emergency Department HMO education series
2012
Investigations
The CXR is hellip
ABG on room air
pH 730 CO2 55
O2 70 HCO3 18
What do the blood gases
show
How severe is the
problem
Emergency Department HMO education series
2012
What scoring tools for
pneumonia
SMARTCOP CURB-65 Sepsis guidelines
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
SMARTCOP
SMARTCOP
SMARTCOP
CURB 65
Various website and apps can assist you in
remembering them wwwmdcalccom
Emergency Department HMO education series
2012
Case B4 - Female in her 60rsquos
Sudden onset SOB (present now for 1 hour quite
severe) right sided pleuritic chest pain
Mild fever
Right total knee replacement 3 days ago
persistent leg swelling since yesterday
Non-smoker
No previous cardiorespiratory disease
Emergency Department HMO education series
2012
What is the differential
diagnosis
Emergency Department HMO education series
2012
What is the differential
diagnosis
Most likely
PE
Next likely
Pneumonia
Less likely
Pneumothorax
Arrhythmia
AMI
Emergency Department HMO education series
2012
On examination amp tests
Tachypnoea and some WOB
RR 24 T 376 HR 110 BP 11070
Sats 93 RA
Chest clear with normal percussion and normal breath
sounds
CXR normal
ABG pH 75 CO2 30mmHg p02 62mmHg on RA
Most likely diagnosis
What are Wells criteria
What are Wells criteria
PERC
D-Dimer
What test do you want to do
Emergency Department HMO education series
2012
What can you see
Emergency Department HMO education series
2012
Filling defect R main pulmonary trunk
Emergency Department HMO education series
2012
Emergency Department HMO education series
2012
Case C Man in 60rsquos
Woke this am very SOB and distressed ndash called
ambulance
Progressive SOB over 6 months
Chronic cough
Usually with white sputum
Now worse with no change in sputum colour
No associated fever
SOB in night ndash gets up
Ankles swollen recently
Heavy smoker (35 pack years)
Admission to local hospital 612 ago with chest pains
Emergency Department HMO education series
2012
Differential diagnosis
CCF with acute exacerbation
Chronic obstructive pulmonary disease
(COPD) with acute infective exacerbation
Anaemia
Emergency Department HMO education series
2012
Exam amp investigationshellip
Unwell RR 36 T 368 HR 90 SR BP 180102
Satrsquos 88 RA
Evidence of work of breathing and use of accessory muscles (which are these)
Pursed lip breathing
Prolonged expiration with wheeze
ABG pH 728 pCO2 60 pO2 55 HCO3 26
What do these show
Do you want a CXR
Emergency Department HMO education series
2012
Emergency Department HMO education series
2012
Diagnosis
Acute cardiac failure ndash APO
Most likely cause
Treatment
ECG ndash filed unsigned and
unseen
Emergency Department HMO education series
2012
Diagnosis
Acute cardiac failure ndash APO
Most likely cause
Treatment
Emergency Department HMO education series
2012
Diagnosis - APO
Acute cardiac failure
Treatment
Medications Nitroglycerin SL topical or IV titrated to avoid hypotension Most rapidly
venodilates reduces LV afterload and corrects myocardial ischaemia
Frusemide IV Despite universal use absolute efficacy is unclear
Ventilatory Assistance Non-invasive ventilation (NIV) reduces mortality by 40 particularly with CPAP
and reduces need to intubate
Emergency Department HMO education series
2012
Case C2 - Male in 60rsquos
Progressive SOB over 6 months worse over 24 hours
Orthopnoea Paroxysmal nocturnal dyspnoea (PND) SOA All present to a minor degree over the 6 months but worse for 24 hours
Palpitations (last 24 hours)
Previous AMI 4 years ago pace maker
Ex-smoker Hypertension (HT) diabetes
Emergency Department HMO education series
2012
Examination
Unwell looking with increased work of breathing
RR 26 afeb HR Irreg 130 BP 10070
Sat 90 RA
JVP 5cm
SOA ++
Displaced apex beat no cardiac murmurs 3rd heart sound present
Normal chest expansion but stony dull percussion in the bases (RgtL) bilateral inspiratory crepitations just above the dull areas
ECG ndash what is your diagnosis
Emergency Department HMO education series
2012
Cardiac failure
Emergency Department HMO education series
2012
Case C2 - Summary
Long standing heart failure with an acute
exacerbation due to new onset rapid AF
Treatment of AF amp heart failure
Antithrombotic strategy
Then rate control
Perhaps rhythm control
See review article re AF treatment
To be published early 2013 Australian Rural Doctor
Case D
Mid 60s male
Found SOB ++ in street
Ambulance called
In ED
SOB at rest
Doesnt want help
Funny smell
Further information
Dishevelled
HR 120 reg BP 9560 Sats 94 RA
Vomiting intermittently
What will you do
Further treatment and
investigation
Further history from patient and collateral
sources
Resuscitation
IV access fluids
Bloods ndash FBC UEC CMP Blood gas
pH 71 pCO2 20 pO2 90 HCO3 10 BE -16
Further treatment and
investigation
Further history from patient and collateral
sources
Resuscitation
IV access fluids
Bloods ndash FBC UEC CMP Blood gas
pH 71 pCO2 20 pO2 90 HCO3 10 BE -16
BSL gt30
Further treatment and
investigation
Treatment
IV fluids ndash caution with Na and cerebral oedema
IV insulin
001 ndash 01 unitskghr
aim for BSL 2mmolL drop per hour
Continue until metabolic correction
Monitor and correct K+ other electrolytes
Monitor urine ketones VBGABG
Identify precipitant
Resolution
Wife arrives and is relieved to find husband
Chairman of Rotary Club
UTI developed whilst wife away for weekend
Questions
Summary
Diagnosis of the breathless patient requires you to look for clueshellip The time course of the illness
Associated symptoms
Known diseases or risk factors for disease
Treatment of illnesses supported by evidence for pneumonia asthma PE AF etc
Interpretation of radiology best done with clinical context
Thankyou
Emergency Department HMO education series
2012
What else should I ask
Travel historyhellip
Other important symptoms of respiratory
disease
Cough
Acute
Chronic
Haemoptysis (cancer TB other infections)
Chest Pain
Daytime sleepiness (obstructive sleep apnea)
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Emergency Department HMO education series
2013
Diagnosis and severity
SOB + associated symptoms = cause or differential diagnosis
SOB + stridor = Inspiratory obstruction eg croup FB
SOB + Pleuritic pain = PE Pneumonia pneumothorax
SOB + wheeze = Asthma COPD lsquocardiac asthmarsquo or APO
SOB + fevercoughsputum = Pneumonia other infection APO
SOB + haemoptysis = Upper airway lesion pneumonia PE cancer
vasculitis
The severity of symptoms
Current distress
Breathless at rest talking on exertion
Oxygen needs
O2 sats oxygen flow and delivery system
Rate of onset and subsequent lsquotrendrsquo
Previous experience of patient (ITU admissions)
Diagnosis and severity
Background history
Expanding on the detail for a differential diagnosis eg
PE - recent travel FHx Wellrsquos criteria PERC score
Eliciting the history for therapeutic guidance
Pneumonia - CURB-65 hospital vs community acquired
immunosuppression contacts incl animals and birds known
recent outbreaks eg Legionella
Ask about
Medications including doses compliance recent changes
Who normally looks after the patient and where
good summary of recent treatment Think the GP specialist
clinic letters recent admissionsdischarge summaries
Emergency Department HMO education series
2012
Paediatrics
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 only observation
The Royal Childrenrsquos clinical guidelines are an excellent
resource to look up while working in the Emergency
Department
httpwwwuhsnhsukMediasuhtidealTopNavigationArticlesSkil
lsForPracticeClinicalSkillspaediatricassessmentpdf
Emergency Department HMO education series
2013
Paediatrics
Cases
Emergency Department HMO education series
2013
Case A
2 yo presents to ED at 2200 with mother
Not distressed (child ndash mother anxious)
Stridor noted at triage
What is your differential
Emergency Department HMO education series
2013
What is your differential
Croup
FB
Epiglottitis
Upper airway massswelling
Functional
Emergency Department HMO education series
2013
Emergency Department HMO education series
2012
What else might you elicit in
the history
What else might you elicit in
the history Recent or current viral illness in child sibs or
kinderchild care
Similar events in the past
Immunisation history (How many doses of Hib and when)
Fluids and food intake
How parentcarer feels about behavior
Possible FB
Emergency Department HMO education series
2013
On review
Child becomes distressed when you
approach and attempt to examine
Remember
Emergency Department HMO education series
2013
Emergency Department HMO education series
2012
On review
Child becomes distressed when you
approach and attempt to examine
Emergency Department HMO education series
2012
On review
Child becomes distressed when you
approach and attempt to examine
St Gurnasty Infirmary Unpleasantshire Hospitals
Services Trust
Kill or be killed
On review
Child becomes distressed when you
approach and attempt to examine
Intercostal recession marked
Tracheal tug noted
Also note respiratory rate O2 requirements
Emergency Department HMO education series
2013
text
Croup
Emergency Department HMO education series
2013
Treatment
Steroids have been shown to decrease the length of hospital stay need for nebulised Adrenaline and
other interventions
Mild to Moderate Croup
Prednisolone 1mgkg AND prescribe a second dose for the next evening OR a single dose of
Oral Dexamethasone 015mgkg Observe for half an hour post steroid administration Discharge
once stridor-free at rest
Severe croup
Nebulised adrenaline (1 mL of 1 adrenaline diluted to 4 ml with Normal Saline or 5ml of adrenaline
11000)
AND
Give 06mgkg (max 12mg) IMIV dexamethasone
Emergency Department HMO education series
2013
Case B
22 yo man
Brought to the ED by his partner
Sudden onset of SOB
Now present for few hours
How is your differential diagnosis affected by
the sudden onset
Emergency Department HMO education series
2013
Further history
Previously well smokes 10 cigarettesday
Left sided chest pain
Moderate
Pleuritic
Started with the SOB
Is there anything else you would like to ask
What is your differential diagnosis
Emergency Department HMO education series
2013
Emergency Department HMO education series
2012
Differential diagnosis
Pneumothorax
Arrhythmia
Pulmonary Embolism
Asthma (less likely)
Pneumonia
Anxiety
Emergency Department HMO education series
2012
Differential diagnosis
Pneumothorax
Arrhythmia
Pulmonary Embolism
Asthma (less likely)
Pneumonia
Anxiety (Imagine that being your diagnosis and you missed a pound$^ your honour)
You horrible
little doctor
Emergency Department HMO education series
2012
Examination findings
Looks unwell quite distressed with WOB
RR 26 HR 125 SR BP 8060 afebrile
Saturation 93 RA (room air)
Trachea midline
chest expansion on the left
Hyper-resonant percussion note on the left
air entry left lung
What is going on
Is this serious
What is your immediate management
Emergency Department HMO education series
2012
Describe this CXR
Emergency Department HMO education series
2012
Describe this CXR
gt or lt 2cm
Where gt 2cm then pneumothorax is gt50 and is considered large
Emergency Department HMO education series
2012
Describe this CXR
Bigger image next slide
Tethered
lung
gt2cm
Right shift of
mediastinum
Air next to
pericardium
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)
Tension
bullLarge bore cannula 2nd intercostal space mid-clavicular line
If large non-tension
bullgt2cm rim (ie gt50)
bull14-18 G cannula safe triangle (or 2ICS if contraindicated) - aspirate
bullDrain 8-14 FG is usually adequate although 28 FG may be required with
mechanical ventilation
Other considerations
bullNo improvement with drain ndash suction cardiothoracic involvement
httpthoraxbmjcomcontent58suppl_2ii39full
httpssecurecollemergencymedacukcodedocumentaspID=6194
Describe the treatment for
Pneumothorax
httpwwwbrit-thoracicorgukPortals0GuidelinesPleuralDiseaseGuidelinesPleural20Guideline202010Pleural20disease20201020pneumothoraxpdf
Emergency Department HMO education series
2012
Case B2
22 yo 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
Emergency Department HMO education series
2012
Further history amp 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
11070
Sat 97 RA
Widespread wheeze
(what causes this
sound)
Emergency Department HMO education series
2012
Investigations
If the CXR is normal (ish)hellip
Peak Flow 250min (how does this help us)
ABG on room air pH 75 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
Emergency Department HMO education series
2012
Investigations
If the CXR is normalhellip
Peak Flow 250min (how does this help us)
ABG on room air pH 75 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
Emergency Department HMO education series
2012
BBH Asthma protocol
Emergency Department HMO education series
2012
Investigations
If the CXR is normalhellip
Peak Flow 250min (how does this help us)
ABG on room air pH 75 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
Emergency Department HMO education series
2012
Investigations
If the CXR is normalhellip
Peak Flow 300min (how does this help us)
ABG on room air pH 75 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
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 httpwwwnationalasthmaorgauhealth-professionalstools-for-primary-careasthma-action-plansasthma-action-
plan-library
Asthma sticker
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 httpwwwnationalasthmaorgauhealth-professionalstools-for-primary-careasthma-action-plansasthma-action-plan-
library
Discharge checklist
Follow up referral letter to GP
Copy of letter with patient (optional)
Current asthma action plan
Triggers identified
Medications prescribed including
Relievers-short acting B agonists
Preventers-steroids
Symptom controllers-long acting B agonists (if prescribed)
Ensure medications will last until arranged review
Spacer or other delivery systems available and patient
understands use and care
Asthma handouts given (patient information fact sheet)
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 httpwwwnationalasthmaorgauhealth-professionalstools-for-primary-careasthma-action-plansasthma-action-
plan-library
Example action plan
Emergency Department HMO education series
2012
Case B3
22 yo man
Brought to the ED by his partner
Gradual onset of SOB
Now present for few hours
What else do you want to know
Emergency Department HMO education series
2012
Further history amp examination
No wheeze
Productive cough
No recent URTI
Childhood asthma (age
3-12) hay fever
No cardiac history
No risk factors for PE
RR 34 HR 110 SR BP
8965
Sat 87 RA
Dull R base with coarse
crackles
Emergency Department HMO education series
2012
Investigations
The CXR is hellip
ABG on room air
pH 730 CO2 55
O2 70 HCO3 18
What do the blood gases
show
How severe is the
problem
Emergency Department HMO education series
2012
What scoring tools for
pneumonia
SMARTCOP CURB-65 Sepsis guidelines
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
SMARTCOP
SMARTCOP
SMARTCOP
CURB 65
Various website and apps can assist you in
remembering them wwwmdcalccom
Emergency Department HMO education series
2012
Case B4 - Female in her 60rsquos
Sudden onset SOB (present now for 1 hour quite
severe) right sided pleuritic chest pain
Mild fever
Right total knee replacement 3 days ago
persistent leg swelling since yesterday
Non-smoker
No previous cardiorespiratory disease
Emergency Department HMO education series
2012
What is the differential
diagnosis
Emergency Department HMO education series
2012
What is the differential
diagnosis
Most likely
PE
Next likely
Pneumonia
Less likely
Pneumothorax
Arrhythmia
AMI
Emergency Department HMO education series
2012
On examination amp tests
Tachypnoea and some WOB
RR 24 T 376 HR 110 BP 11070
Sats 93 RA
Chest clear with normal percussion and normal breath
sounds
CXR normal
ABG pH 75 CO2 30mmHg p02 62mmHg on RA
Most likely diagnosis
What are Wells criteria
What are Wells criteria
PERC
D-Dimer
What test do you want to do
Emergency Department HMO education series
2012
What can you see
Emergency Department HMO education series
2012
Filling defect R main pulmonary trunk
Emergency Department HMO education series
2012
Emergency Department HMO education series
2012
Case C Man in 60rsquos
Woke this am very SOB and distressed ndash called
ambulance
Progressive SOB over 6 months
Chronic cough
Usually with white sputum
Now worse with no change in sputum colour
No associated fever
SOB in night ndash gets up
Ankles swollen recently
Heavy smoker (35 pack years)
Admission to local hospital 612 ago with chest pains
Emergency Department HMO education series
2012
Differential diagnosis
CCF with acute exacerbation
Chronic obstructive pulmonary disease
(COPD) with acute infective exacerbation
Anaemia
Emergency Department HMO education series
2012
Exam amp investigationshellip
Unwell RR 36 T 368 HR 90 SR BP 180102
Satrsquos 88 RA
Evidence of work of breathing and use of accessory muscles (which are these)
Pursed lip breathing
Prolonged expiration with wheeze
ABG pH 728 pCO2 60 pO2 55 HCO3 26
What do these show
Do you want a CXR
Emergency Department HMO education series
2012
Emergency Department HMO education series
2012
Diagnosis
Acute cardiac failure ndash APO
Most likely cause
Treatment
ECG ndash filed unsigned and
unseen
Emergency Department HMO education series
2012
Diagnosis
Acute cardiac failure ndash APO
Most likely cause
Treatment
Emergency Department HMO education series
2012
Diagnosis - APO
Acute cardiac failure
Treatment
Medications Nitroglycerin SL topical or IV titrated to avoid hypotension Most rapidly
venodilates reduces LV afterload and corrects myocardial ischaemia
Frusemide IV Despite universal use absolute efficacy is unclear
Ventilatory Assistance Non-invasive ventilation (NIV) reduces mortality by 40 particularly with CPAP
and reduces need to intubate
Emergency Department HMO education series
2012
Case C2 - Male in 60rsquos
Progressive SOB over 6 months worse over 24 hours
Orthopnoea Paroxysmal nocturnal dyspnoea (PND) SOA All present to a minor degree over the 6 months but worse for 24 hours
Palpitations (last 24 hours)
Previous AMI 4 years ago pace maker
Ex-smoker Hypertension (HT) diabetes
Emergency Department HMO education series
2012
Examination
Unwell looking with increased work of breathing
RR 26 afeb HR Irreg 130 BP 10070
Sat 90 RA
JVP 5cm
SOA ++
Displaced apex beat no cardiac murmurs 3rd heart sound present
Normal chest expansion but stony dull percussion in the bases (RgtL) bilateral inspiratory crepitations just above the dull areas
ECG ndash what is your diagnosis
Emergency Department HMO education series
2012
Cardiac failure
Emergency Department HMO education series
2012
Case C2 - Summary
Long standing heart failure with an acute
exacerbation due to new onset rapid AF
Treatment of AF amp heart failure
Antithrombotic strategy
Then rate control
Perhaps rhythm control
See review article re AF treatment
To be published early 2013 Australian Rural Doctor
Case D
Mid 60s male
Found SOB ++ in street
Ambulance called
In ED
SOB at rest
Doesnt want help
Funny smell
Further information
Dishevelled
HR 120 reg BP 9560 Sats 94 RA
Vomiting intermittently
What will you do
Further treatment and
investigation
Further history from patient and collateral
sources
Resuscitation
IV access fluids
Bloods ndash FBC UEC CMP Blood gas
pH 71 pCO2 20 pO2 90 HCO3 10 BE -16
Further treatment and
investigation
Further history from patient and collateral
sources
Resuscitation
IV access fluids
Bloods ndash FBC UEC CMP Blood gas
pH 71 pCO2 20 pO2 90 HCO3 10 BE -16
BSL gt30
Further treatment and
investigation
Treatment
IV fluids ndash caution with Na and cerebral oedema
IV insulin
001 ndash 01 unitskghr
aim for BSL 2mmolL drop per hour
Continue until metabolic correction
Monitor and correct K+ other electrolytes
Monitor urine ketones VBGABG
Identify precipitant
Resolution
Wife arrives and is relieved to find husband
Chairman of Rotary Club
UTI developed whilst wife away for weekend
Questions
Summary
Diagnosis of the breathless patient requires you to look for clueshellip The time course of the illness
Associated symptoms
Known diseases or risk factors for disease
Treatment of illnesses supported by evidence for pneumonia asthma PE AF etc
Interpretation of radiology best done with clinical context
Thankyou
Emergency Department HMO education series
2012
What else should I ask
Travel historyhellip
Other important symptoms of respiratory
disease
Cough
Acute
Chronic
Haemoptysis (cancer TB other infections)
Chest Pain
Daytime sleepiness (obstructive sleep apnea)
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
The severity of symptoms
Current distress
Breathless at rest talking on exertion
Oxygen needs
O2 sats oxygen flow and delivery system
Rate of onset and subsequent lsquotrendrsquo
Previous experience of patient (ITU admissions)
Diagnosis and severity
Background history
Expanding on the detail for a differential diagnosis eg
PE - recent travel FHx Wellrsquos criteria PERC score
Eliciting the history for therapeutic guidance
Pneumonia - CURB-65 hospital vs community acquired
immunosuppression contacts incl animals and birds known
recent outbreaks eg Legionella
Ask about
Medications including doses compliance recent changes
Who normally looks after the patient and where
good summary of recent treatment Think the GP specialist
clinic letters recent admissionsdischarge summaries
Emergency Department HMO education series
2012
Paediatrics
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 only observation
The Royal Childrenrsquos clinical guidelines are an excellent
resource to look up while working in the Emergency
Department
httpwwwuhsnhsukMediasuhtidealTopNavigationArticlesSkil
lsForPracticeClinicalSkillspaediatricassessmentpdf
Emergency Department HMO education series
2013
Paediatrics
Cases
Emergency Department HMO education series
2013
Case A
2 yo presents to ED at 2200 with mother
Not distressed (child ndash mother anxious)
Stridor noted at triage
What is your differential
Emergency Department HMO education series
2013
What is your differential
Croup
FB
Epiglottitis
Upper airway massswelling
Functional
Emergency Department HMO education series
2013
Emergency Department HMO education series
2012
What else might you elicit in
the history
What else might you elicit in
the history Recent or current viral illness in child sibs or
kinderchild care
Similar events in the past
Immunisation history (How many doses of Hib and when)
Fluids and food intake
How parentcarer feels about behavior
Possible FB
Emergency Department HMO education series
2013
On review
Child becomes distressed when you
approach and attempt to examine
Remember
Emergency Department HMO education series
2013
Emergency Department HMO education series
2012
On review
Child becomes distressed when you
approach and attempt to examine
Emergency Department HMO education series
2012
On review
Child becomes distressed when you
approach and attempt to examine
St Gurnasty Infirmary Unpleasantshire Hospitals
Services Trust
Kill or be killed
On review
Child becomes distressed when you
approach and attempt to examine
Intercostal recession marked
Tracheal tug noted
Also note respiratory rate O2 requirements
Emergency Department HMO education series
2013
text
Croup
Emergency Department HMO education series
2013
Treatment
Steroids have been shown to decrease the length of hospital stay need for nebulised Adrenaline and
other interventions
Mild to Moderate Croup
Prednisolone 1mgkg AND prescribe a second dose for the next evening OR a single dose of
Oral Dexamethasone 015mgkg Observe for half an hour post steroid administration Discharge
once stridor-free at rest
Severe croup
Nebulised adrenaline (1 mL of 1 adrenaline diluted to 4 ml with Normal Saline or 5ml of adrenaline
11000)
AND
Give 06mgkg (max 12mg) IMIV dexamethasone
Emergency Department HMO education series
2013
Case B
22 yo man
Brought to the ED by his partner
Sudden onset of SOB
Now present for few hours
How is your differential diagnosis affected by
the sudden onset
Emergency Department HMO education series
2013
Further history
Previously well smokes 10 cigarettesday
Left sided chest pain
Moderate
Pleuritic
Started with the SOB
Is there anything else you would like to ask
What is your differential diagnosis
Emergency Department HMO education series
2013
Emergency Department HMO education series
2012
Differential diagnosis
Pneumothorax
Arrhythmia
Pulmonary Embolism
Asthma (less likely)
Pneumonia
Anxiety
Emergency Department HMO education series
2012
Differential diagnosis
Pneumothorax
Arrhythmia
Pulmonary Embolism
Asthma (less likely)
Pneumonia
Anxiety (Imagine that being your diagnosis and you missed a pound$^ your honour)
You horrible
little doctor
Emergency Department HMO education series
2012
Examination findings
Looks unwell quite distressed with WOB
RR 26 HR 125 SR BP 8060 afebrile
Saturation 93 RA (room air)
Trachea midline
chest expansion on the left
Hyper-resonant percussion note on the left
air entry left lung
What is going on
Is this serious
What is your immediate management
Emergency Department HMO education series
2012
Describe this CXR
Emergency Department HMO education series
2012
Describe this CXR
gt or lt 2cm
Where gt 2cm then pneumothorax is gt50 and is considered large
Emergency Department HMO education series
2012
Describe this CXR
Bigger image next slide
Tethered
lung
gt2cm
Right shift of
mediastinum
Air next to
pericardium
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)
Tension
bullLarge bore cannula 2nd intercostal space mid-clavicular line
If large non-tension
bullgt2cm rim (ie gt50)
bull14-18 G cannula safe triangle (or 2ICS if contraindicated) - aspirate
bullDrain 8-14 FG is usually adequate although 28 FG may be required with
mechanical ventilation
Other considerations
bullNo improvement with drain ndash suction cardiothoracic involvement
httpthoraxbmjcomcontent58suppl_2ii39full
httpssecurecollemergencymedacukcodedocumentaspID=6194
Describe the treatment for
Pneumothorax
httpwwwbrit-thoracicorgukPortals0GuidelinesPleuralDiseaseGuidelinesPleural20Guideline202010Pleural20disease20201020pneumothoraxpdf
Emergency Department HMO education series
2012
Case B2
22 yo 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
Emergency Department HMO education series
2012
Further history amp 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
11070
Sat 97 RA
Widespread wheeze
(what causes this
sound)
Emergency Department HMO education series
2012
Investigations
If the CXR is normal (ish)hellip
Peak Flow 250min (how does this help us)
ABG on room air pH 75 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
Emergency Department HMO education series
2012
Investigations
If the CXR is normalhellip
Peak Flow 250min (how does this help us)
ABG on room air pH 75 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
Emergency Department HMO education series
2012
BBH Asthma protocol
Emergency Department HMO education series
2012
Investigations
If the CXR is normalhellip
Peak Flow 250min (how does this help us)
ABG on room air pH 75 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
Emergency Department HMO education series
2012
Investigations
If the CXR is normalhellip
Peak Flow 300min (how does this help us)
ABG on room air pH 75 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
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 httpwwwnationalasthmaorgauhealth-professionalstools-for-primary-careasthma-action-plansasthma-action-
plan-library
Asthma sticker
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 httpwwwnationalasthmaorgauhealth-professionalstools-for-primary-careasthma-action-plansasthma-action-plan-
library
Discharge checklist
Follow up referral letter to GP
Copy of letter with patient (optional)
Current asthma action plan
Triggers identified
Medications prescribed including
Relievers-short acting B agonists
Preventers-steroids
Symptom controllers-long acting B agonists (if prescribed)
Ensure medications will last until arranged review
Spacer or other delivery systems available and patient
understands use and care
Asthma handouts given (patient information fact sheet)
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 httpwwwnationalasthmaorgauhealth-professionalstools-for-primary-careasthma-action-plansasthma-action-
plan-library
Example action plan
Emergency Department HMO education series
2012
Case B3
22 yo man
Brought to the ED by his partner
Gradual onset of SOB
Now present for few hours
What else do you want to know
Emergency Department HMO education series
2012
Further history amp examination
No wheeze
Productive cough
No recent URTI
Childhood asthma (age
3-12) hay fever
No cardiac history
No risk factors for PE
RR 34 HR 110 SR BP
8965
Sat 87 RA
Dull R base with coarse
crackles
Emergency Department HMO education series
2012
Investigations
The CXR is hellip
ABG on room air
pH 730 CO2 55
O2 70 HCO3 18
What do the blood gases
show
How severe is the
problem
Emergency Department HMO education series
2012
What scoring tools for
pneumonia
SMARTCOP CURB-65 Sepsis guidelines
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
SMARTCOP
SMARTCOP
SMARTCOP
CURB 65
Various website and apps can assist you in
remembering them wwwmdcalccom
Emergency Department HMO education series
2012
Case B4 - Female in her 60rsquos
Sudden onset SOB (present now for 1 hour quite
severe) right sided pleuritic chest pain
Mild fever
Right total knee replacement 3 days ago
persistent leg swelling since yesterday
Non-smoker
No previous cardiorespiratory disease
Emergency Department HMO education series
2012
What is the differential
diagnosis
Emergency Department HMO education series
2012
What is the differential
diagnosis
Most likely
PE
Next likely
Pneumonia
Less likely
Pneumothorax
Arrhythmia
AMI
Emergency Department HMO education series
2012
On examination amp tests
Tachypnoea and some WOB
RR 24 T 376 HR 110 BP 11070
Sats 93 RA
Chest clear with normal percussion and normal breath
sounds
CXR normal
ABG pH 75 CO2 30mmHg p02 62mmHg on RA
Most likely diagnosis
What are Wells criteria
What are Wells criteria
PERC
D-Dimer
What test do you want to do
Emergency Department HMO education series
2012
What can you see
Emergency Department HMO education series
2012
Filling defect R main pulmonary trunk
Emergency Department HMO education series
2012
Emergency Department HMO education series
2012
Case C Man in 60rsquos
Woke this am very SOB and distressed ndash called
ambulance
Progressive SOB over 6 months
Chronic cough
Usually with white sputum
Now worse with no change in sputum colour
No associated fever
SOB in night ndash gets up
Ankles swollen recently
Heavy smoker (35 pack years)
Admission to local hospital 612 ago with chest pains
Emergency Department HMO education series
2012
Differential diagnosis
CCF with acute exacerbation
Chronic obstructive pulmonary disease
(COPD) with acute infective exacerbation
Anaemia
Emergency Department HMO education series
2012
Exam amp investigationshellip
Unwell RR 36 T 368 HR 90 SR BP 180102
Satrsquos 88 RA
Evidence of work of breathing and use of accessory muscles (which are these)
Pursed lip breathing
Prolonged expiration with wheeze
ABG pH 728 pCO2 60 pO2 55 HCO3 26
What do these show
Do you want a CXR
Emergency Department HMO education series
2012
Emergency Department HMO education series
2012
Diagnosis
Acute cardiac failure ndash APO
Most likely cause
Treatment
ECG ndash filed unsigned and
unseen
Emergency Department HMO education series
2012
Diagnosis
Acute cardiac failure ndash APO
Most likely cause
Treatment
Emergency Department HMO education series
2012
Diagnosis - APO
Acute cardiac failure
Treatment
Medications Nitroglycerin SL topical or IV titrated to avoid hypotension Most rapidly
venodilates reduces LV afterload and corrects myocardial ischaemia
Frusemide IV Despite universal use absolute efficacy is unclear
Ventilatory Assistance Non-invasive ventilation (NIV) reduces mortality by 40 particularly with CPAP
and reduces need to intubate
Emergency Department HMO education series
2012
Case C2 - Male in 60rsquos
Progressive SOB over 6 months worse over 24 hours
Orthopnoea Paroxysmal nocturnal dyspnoea (PND) SOA All present to a minor degree over the 6 months but worse for 24 hours
Palpitations (last 24 hours)
Previous AMI 4 years ago pace maker
Ex-smoker Hypertension (HT) diabetes
Emergency Department HMO education series
2012
Examination
Unwell looking with increased work of breathing
RR 26 afeb HR Irreg 130 BP 10070
Sat 90 RA
JVP 5cm
SOA ++
Displaced apex beat no cardiac murmurs 3rd heart sound present
Normal chest expansion but stony dull percussion in the bases (RgtL) bilateral inspiratory crepitations just above the dull areas
ECG ndash what is your diagnosis
Emergency Department HMO education series
2012
Cardiac failure
Emergency Department HMO education series
2012
Case C2 - Summary
Long standing heart failure with an acute
exacerbation due to new onset rapid AF
Treatment of AF amp heart failure
Antithrombotic strategy
Then rate control
Perhaps rhythm control
See review article re AF treatment
To be published early 2013 Australian Rural Doctor
Case D
Mid 60s male
Found SOB ++ in street
Ambulance called
In ED
SOB at rest
Doesnt want help
Funny smell
Further information
Dishevelled
HR 120 reg BP 9560 Sats 94 RA
Vomiting intermittently
What will you do
Further treatment and
investigation
Further history from patient and collateral
sources
Resuscitation
IV access fluids
Bloods ndash FBC UEC CMP Blood gas
pH 71 pCO2 20 pO2 90 HCO3 10 BE -16
Further treatment and
investigation
Further history from patient and collateral
sources
Resuscitation
IV access fluids
Bloods ndash FBC UEC CMP Blood gas
pH 71 pCO2 20 pO2 90 HCO3 10 BE -16
BSL gt30
Further treatment and
investigation
Treatment
IV fluids ndash caution with Na and cerebral oedema
IV insulin
001 ndash 01 unitskghr
aim for BSL 2mmolL drop per hour
Continue until metabolic correction
Monitor and correct K+ other electrolytes
Monitor urine ketones VBGABG
Identify precipitant
Resolution
Wife arrives and is relieved to find husband
Chairman of Rotary Club
UTI developed whilst wife away for weekend
Questions
Summary
Diagnosis of the breathless patient requires you to look for clueshellip The time course of the illness
Associated symptoms
Known diseases or risk factors for disease
Treatment of illnesses supported by evidence for pneumonia asthma PE AF etc
Interpretation of radiology best done with clinical context
Thankyou
Emergency Department HMO education series
2012
What else should I ask
Travel historyhellip
Other important symptoms of respiratory
disease
Cough
Acute
Chronic
Haemoptysis (cancer TB other infections)
Chest Pain
Daytime sleepiness (obstructive sleep apnea)
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Background history
Expanding on the detail for a differential diagnosis eg
PE - recent travel FHx Wellrsquos criteria PERC score
Eliciting the history for therapeutic guidance
Pneumonia - CURB-65 hospital vs community acquired
immunosuppression contacts incl animals and birds known
recent outbreaks eg Legionella
Ask about
Medications including doses compliance recent changes
Who normally looks after the patient and where
good summary of recent treatment Think the GP specialist
clinic letters recent admissionsdischarge summaries
Emergency Department HMO education series
2012
Paediatrics
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 only observation
The Royal Childrenrsquos clinical guidelines are an excellent
resource to look up while working in the Emergency
Department
httpwwwuhsnhsukMediasuhtidealTopNavigationArticlesSkil
lsForPracticeClinicalSkillspaediatricassessmentpdf
Emergency Department HMO education series
2013
Paediatrics
Cases
Emergency Department HMO education series
2013
Case A
2 yo presents to ED at 2200 with mother
Not distressed (child ndash mother anxious)
Stridor noted at triage
What is your differential
Emergency Department HMO education series
2013
What is your differential
Croup
FB
Epiglottitis
Upper airway massswelling
Functional
Emergency Department HMO education series
2013
Emergency Department HMO education series
2012
What else might you elicit in
the history
What else might you elicit in
the history Recent or current viral illness in child sibs or
kinderchild care
Similar events in the past
Immunisation history (How many doses of Hib and when)
Fluids and food intake
How parentcarer feels about behavior
Possible FB
Emergency Department HMO education series
2013
On review
Child becomes distressed when you
approach and attempt to examine
Remember
Emergency Department HMO education series
2013
Emergency Department HMO education series
2012
On review
Child becomes distressed when you
approach and attempt to examine
Emergency Department HMO education series
2012
On review
Child becomes distressed when you
approach and attempt to examine
St Gurnasty Infirmary Unpleasantshire Hospitals
Services Trust
Kill or be killed
On review
Child becomes distressed when you
approach and attempt to examine
Intercostal recession marked
Tracheal tug noted
Also note respiratory rate O2 requirements
Emergency Department HMO education series
2013
text
Croup
Emergency Department HMO education series
2013
Treatment
Steroids have been shown to decrease the length of hospital stay need for nebulised Adrenaline and
other interventions
Mild to Moderate Croup
Prednisolone 1mgkg AND prescribe a second dose for the next evening OR a single dose of
Oral Dexamethasone 015mgkg Observe for half an hour post steroid administration Discharge
once stridor-free at rest
Severe croup
Nebulised adrenaline (1 mL of 1 adrenaline diluted to 4 ml with Normal Saline or 5ml of adrenaline
11000)
AND
Give 06mgkg (max 12mg) IMIV dexamethasone
Emergency Department HMO education series
2013
Case B
22 yo man
Brought to the ED by his partner
Sudden onset of SOB
Now present for few hours
How is your differential diagnosis affected by
the sudden onset
Emergency Department HMO education series
2013
Further history
Previously well smokes 10 cigarettesday
Left sided chest pain
Moderate
Pleuritic
Started with the SOB
Is there anything else you would like to ask
What is your differential diagnosis
Emergency Department HMO education series
2013
Emergency Department HMO education series
2012
Differential diagnosis
Pneumothorax
Arrhythmia
Pulmonary Embolism
Asthma (less likely)
Pneumonia
Anxiety
Emergency Department HMO education series
2012
Differential diagnosis
Pneumothorax
Arrhythmia
Pulmonary Embolism
Asthma (less likely)
Pneumonia
Anxiety (Imagine that being your diagnosis and you missed a pound$^ your honour)
You horrible
little doctor
Emergency Department HMO education series
2012
Examination findings
Looks unwell quite distressed with WOB
RR 26 HR 125 SR BP 8060 afebrile
Saturation 93 RA (room air)
Trachea midline
chest expansion on the left
Hyper-resonant percussion note on the left
air entry left lung
What is going on
Is this serious
What is your immediate management
Emergency Department HMO education series
2012
Describe this CXR
Emergency Department HMO education series
2012
Describe this CXR
gt or lt 2cm
Where gt 2cm then pneumothorax is gt50 and is considered large
Emergency Department HMO education series
2012
Describe this CXR
Bigger image next slide
Tethered
lung
gt2cm
Right shift of
mediastinum
Air next to
pericardium
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)
Tension
bullLarge bore cannula 2nd intercostal space mid-clavicular line
If large non-tension
bullgt2cm rim (ie gt50)
bull14-18 G cannula safe triangle (or 2ICS if contraindicated) - aspirate
bullDrain 8-14 FG is usually adequate although 28 FG may be required with
mechanical ventilation
Other considerations
bullNo improvement with drain ndash suction cardiothoracic involvement
httpthoraxbmjcomcontent58suppl_2ii39full
httpssecurecollemergencymedacukcodedocumentaspID=6194
Describe the treatment for
Pneumothorax
httpwwwbrit-thoracicorgukPortals0GuidelinesPleuralDiseaseGuidelinesPleural20Guideline202010Pleural20disease20201020pneumothoraxpdf
Emergency Department HMO education series
2012
Case B2
22 yo 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
Emergency Department HMO education series
2012
Further history amp 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
11070
Sat 97 RA
Widespread wheeze
(what causes this
sound)
Emergency Department HMO education series
2012
Investigations
If the CXR is normal (ish)hellip
Peak Flow 250min (how does this help us)
ABG on room air pH 75 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
Emergency Department HMO education series
2012
Investigations
If the CXR is normalhellip
Peak Flow 250min (how does this help us)
ABG on room air pH 75 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
Emergency Department HMO education series
2012
BBH Asthma protocol
Emergency Department HMO education series
2012
Investigations
If the CXR is normalhellip
Peak Flow 250min (how does this help us)
ABG on room air pH 75 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
Emergency Department HMO education series
2012
Investigations
If the CXR is normalhellip
Peak Flow 300min (how does this help us)
ABG on room air pH 75 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
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 httpwwwnationalasthmaorgauhealth-professionalstools-for-primary-careasthma-action-plansasthma-action-
plan-library
Asthma sticker
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 httpwwwnationalasthmaorgauhealth-professionalstools-for-primary-careasthma-action-plansasthma-action-plan-
library
Discharge checklist
Follow up referral letter to GP
Copy of letter with patient (optional)
Current asthma action plan
Triggers identified
Medications prescribed including
Relievers-short acting B agonists
Preventers-steroids
Symptom controllers-long acting B agonists (if prescribed)
Ensure medications will last until arranged review
Spacer or other delivery systems available and patient
understands use and care
Asthma handouts given (patient information fact sheet)
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 httpwwwnationalasthmaorgauhealth-professionalstools-for-primary-careasthma-action-plansasthma-action-
plan-library
Example action plan
Emergency Department HMO education series
2012
Case B3
22 yo man
Brought to the ED by his partner
Gradual onset of SOB
Now present for few hours
What else do you want to know
Emergency Department HMO education series
2012
Further history amp examination
No wheeze
Productive cough
No recent URTI
Childhood asthma (age
3-12) hay fever
No cardiac history
No risk factors for PE
RR 34 HR 110 SR BP
8965
Sat 87 RA
Dull R base with coarse
crackles
Emergency Department HMO education series
2012
Investigations
The CXR is hellip
ABG on room air
pH 730 CO2 55
O2 70 HCO3 18
What do the blood gases
show
How severe is the
problem
Emergency Department HMO education series
2012
What scoring tools for
pneumonia
SMARTCOP CURB-65 Sepsis guidelines
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
SMARTCOP
SMARTCOP
SMARTCOP
CURB 65
Various website and apps can assist you in
remembering them wwwmdcalccom
Emergency Department HMO education series
2012
Case B4 - Female in her 60rsquos
Sudden onset SOB (present now for 1 hour quite
severe) right sided pleuritic chest pain
Mild fever
Right total knee replacement 3 days ago
persistent leg swelling since yesterday
Non-smoker
No previous cardiorespiratory disease
Emergency Department HMO education series
2012
What is the differential
diagnosis
Emergency Department HMO education series
2012
What is the differential
diagnosis
Most likely
PE
Next likely
Pneumonia
Less likely
Pneumothorax
Arrhythmia
AMI
Emergency Department HMO education series
2012
On examination amp tests
Tachypnoea and some WOB
RR 24 T 376 HR 110 BP 11070
Sats 93 RA
Chest clear with normal percussion and normal breath
sounds
CXR normal
ABG pH 75 CO2 30mmHg p02 62mmHg on RA
Most likely diagnosis
What are Wells criteria
What are Wells criteria
PERC
D-Dimer
What test do you want to do
Emergency Department HMO education series
2012
What can you see
Emergency Department HMO education series
2012
Filling defect R main pulmonary trunk
Emergency Department HMO education series
2012
Emergency Department HMO education series
2012
Case C Man in 60rsquos
Woke this am very SOB and distressed ndash called
ambulance
Progressive SOB over 6 months
Chronic cough
Usually with white sputum
Now worse with no change in sputum colour
No associated fever
SOB in night ndash gets up
Ankles swollen recently
Heavy smoker (35 pack years)
Admission to local hospital 612 ago with chest pains
Emergency Department HMO education series
2012
Differential diagnosis
CCF with acute exacerbation
Chronic obstructive pulmonary disease
(COPD) with acute infective exacerbation
Anaemia
Emergency Department HMO education series
2012
Exam amp investigationshellip
Unwell RR 36 T 368 HR 90 SR BP 180102
Satrsquos 88 RA
Evidence of work of breathing and use of accessory muscles (which are these)
Pursed lip breathing
Prolonged expiration with wheeze
ABG pH 728 pCO2 60 pO2 55 HCO3 26
What do these show
Do you want a CXR
Emergency Department HMO education series
2012
Emergency Department HMO education series
2012
Diagnosis
Acute cardiac failure ndash APO
Most likely cause
Treatment
ECG ndash filed unsigned and
unseen
Emergency Department HMO education series
2012
Diagnosis
Acute cardiac failure ndash APO
Most likely cause
Treatment
Emergency Department HMO education series
2012
Diagnosis - APO
Acute cardiac failure
Treatment
Medications Nitroglycerin SL topical or IV titrated to avoid hypotension Most rapidly
venodilates reduces LV afterload and corrects myocardial ischaemia
Frusemide IV Despite universal use absolute efficacy is unclear
Ventilatory Assistance Non-invasive ventilation (NIV) reduces mortality by 40 particularly with CPAP
and reduces need to intubate
Emergency Department HMO education series
2012
Case C2 - Male in 60rsquos
Progressive SOB over 6 months worse over 24 hours
Orthopnoea Paroxysmal nocturnal dyspnoea (PND) SOA All present to a minor degree over the 6 months but worse for 24 hours
Palpitations (last 24 hours)
Previous AMI 4 years ago pace maker
Ex-smoker Hypertension (HT) diabetes
Emergency Department HMO education series
2012
Examination
Unwell looking with increased work of breathing
RR 26 afeb HR Irreg 130 BP 10070
Sat 90 RA
JVP 5cm
SOA ++
Displaced apex beat no cardiac murmurs 3rd heart sound present
Normal chest expansion but stony dull percussion in the bases (RgtL) bilateral inspiratory crepitations just above the dull areas
ECG ndash what is your diagnosis
Emergency Department HMO education series
2012
Cardiac failure
Emergency Department HMO education series
2012
Case C2 - Summary
Long standing heart failure with an acute
exacerbation due to new onset rapid AF
Treatment of AF amp heart failure
Antithrombotic strategy
Then rate control
Perhaps rhythm control
See review article re AF treatment
To be published early 2013 Australian Rural Doctor
Case D
Mid 60s male
Found SOB ++ in street
Ambulance called
In ED
SOB at rest
Doesnt want help
Funny smell
Further information
Dishevelled
HR 120 reg BP 9560 Sats 94 RA
Vomiting intermittently
What will you do
Further treatment and
investigation
Further history from patient and collateral
sources
Resuscitation
IV access fluids
Bloods ndash FBC UEC CMP Blood gas
pH 71 pCO2 20 pO2 90 HCO3 10 BE -16
Further treatment and
investigation
Further history from patient and collateral
sources
Resuscitation
IV access fluids
Bloods ndash FBC UEC CMP Blood gas
pH 71 pCO2 20 pO2 90 HCO3 10 BE -16
BSL gt30
Further treatment and
investigation
Treatment
IV fluids ndash caution with Na and cerebral oedema
IV insulin
001 ndash 01 unitskghr
aim for BSL 2mmolL drop per hour
Continue until metabolic correction
Monitor and correct K+ other electrolytes
Monitor urine ketones VBGABG
Identify precipitant
Resolution
Wife arrives and is relieved to find husband
Chairman of Rotary Club
UTI developed whilst wife away for weekend
Questions
Summary
Diagnosis of the breathless patient requires you to look for clueshellip The time course of the illness
Associated symptoms
Known diseases or risk factors for disease
Treatment of illnesses supported by evidence for pneumonia asthma PE AF etc
Interpretation of radiology best done with clinical context
Thankyou
Emergency Department HMO education series
2012
What else should I ask
Travel historyhellip
Other important symptoms of respiratory
disease
Cough
Acute
Chronic
Haemoptysis (cancer TB other infections)
Chest Pain
Daytime sleepiness (obstructive sleep apnea)
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Emergency Department HMO education series
2012
Paediatrics
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 only observation
The Royal Childrenrsquos clinical guidelines are an excellent
resource to look up while working in the Emergency
Department
httpwwwuhsnhsukMediasuhtidealTopNavigationArticlesSkil
lsForPracticeClinicalSkillspaediatricassessmentpdf
Emergency Department HMO education series
2013
Paediatrics
Cases
Emergency Department HMO education series
2013
Case A
2 yo presents to ED at 2200 with mother
Not distressed (child ndash mother anxious)
Stridor noted at triage
What is your differential
Emergency Department HMO education series
2013
What is your differential
Croup
FB
Epiglottitis
Upper airway massswelling
Functional
Emergency Department HMO education series
2013
Emergency Department HMO education series
2012
What else might you elicit in
the history
What else might you elicit in
the history Recent or current viral illness in child sibs or
kinderchild care
Similar events in the past
Immunisation history (How many doses of Hib and when)
Fluids and food intake
How parentcarer feels about behavior
Possible FB
Emergency Department HMO education series
2013
On review
Child becomes distressed when you
approach and attempt to examine
Remember
Emergency Department HMO education series
2013
Emergency Department HMO education series
2012
On review
Child becomes distressed when you
approach and attempt to examine
Emergency Department HMO education series
2012
On review
Child becomes distressed when you
approach and attempt to examine
St Gurnasty Infirmary Unpleasantshire Hospitals
Services Trust
Kill or be killed
On review
Child becomes distressed when you
approach and attempt to examine
Intercostal recession marked
Tracheal tug noted
Also note respiratory rate O2 requirements
Emergency Department HMO education series
2013
text
Croup
Emergency Department HMO education series
2013
Treatment
Steroids have been shown to decrease the length of hospital stay need for nebulised Adrenaline and
other interventions
Mild to Moderate Croup
Prednisolone 1mgkg AND prescribe a second dose for the next evening OR a single dose of
Oral Dexamethasone 015mgkg Observe for half an hour post steroid administration Discharge
once stridor-free at rest
Severe croup
Nebulised adrenaline (1 mL of 1 adrenaline diluted to 4 ml with Normal Saline or 5ml of adrenaline
11000)
AND
Give 06mgkg (max 12mg) IMIV dexamethasone
Emergency Department HMO education series
2013
Case B
22 yo man
Brought to the ED by his partner
Sudden onset of SOB
Now present for few hours
How is your differential diagnosis affected by
the sudden onset
Emergency Department HMO education series
2013
Further history
Previously well smokes 10 cigarettesday
Left sided chest pain
Moderate
Pleuritic
Started with the SOB
Is there anything else you would like to ask
What is your differential diagnosis
Emergency Department HMO education series
2013
Emergency Department HMO education series
2012
Differential diagnosis
Pneumothorax
Arrhythmia
Pulmonary Embolism
Asthma (less likely)
Pneumonia
Anxiety
Emergency Department HMO education series
2012
Differential diagnosis
Pneumothorax
Arrhythmia
Pulmonary Embolism
Asthma (less likely)
Pneumonia
Anxiety (Imagine that being your diagnosis and you missed a pound$^ your honour)
You horrible
little doctor
Emergency Department HMO education series
2012
Examination findings
Looks unwell quite distressed with WOB
RR 26 HR 125 SR BP 8060 afebrile
Saturation 93 RA (room air)
Trachea midline
chest expansion on the left
Hyper-resonant percussion note on the left
air entry left lung
What is going on
Is this serious
What is your immediate management
Emergency Department HMO education series
2012
Describe this CXR
Emergency Department HMO education series
2012
Describe this CXR
gt or lt 2cm
Where gt 2cm then pneumothorax is gt50 and is considered large
Emergency Department HMO education series
2012
Describe this CXR
Bigger image next slide
Tethered
lung
gt2cm
Right shift of
mediastinum
Air next to
pericardium
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)
Tension
bullLarge bore cannula 2nd intercostal space mid-clavicular line
If large non-tension
bullgt2cm rim (ie gt50)
bull14-18 G cannula safe triangle (or 2ICS if contraindicated) - aspirate
bullDrain 8-14 FG is usually adequate although 28 FG may be required with
mechanical ventilation
Other considerations
bullNo improvement with drain ndash suction cardiothoracic involvement
httpthoraxbmjcomcontent58suppl_2ii39full
httpssecurecollemergencymedacukcodedocumentaspID=6194
Describe the treatment for
Pneumothorax
httpwwwbrit-thoracicorgukPortals0GuidelinesPleuralDiseaseGuidelinesPleural20Guideline202010Pleural20disease20201020pneumothoraxpdf
Emergency Department HMO education series
2012
Case B2
22 yo 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
Emergency Department HMO education series
2012
Further history amp 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
11070
Sat 97 RA
Widespread wheeze
(what causes this
sound)
Emergency Department HMO education series
2012
Investigations
If the CXR is normal (ish)hellip
Peak Flow 250min (how does this help us)
ABG on room air pH 75 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
Emergency Department HMO education series
2012
Investigations
If the CXR is normalhellip
Peak Flow 250min (how does this help us)
ABG on room air pH 75 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
Emergency Department HMO education series
2012
BBH Asthma protocol
Emergency Department HMO education series
2012
Investigations
If the CXR is normalhellip
Peak Flow 250min (how does this help us)
ABG on room air pH 75 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
Emergency Department HMO education series
2012
Investigations
If the CXR is normalhellip
Peak Flow 300min (how does this help us)
ABG on room air pH 75 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
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 httpwwwnationalasthmaorgauhealth-professionalstools-for-primary-careasthma-action-plansasthma-action-
plan-library
Asthma sticker
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 httpwwwnationalasthmaorgauhealth-professionalstools-for-primary-careasthma-action-plansasthma-action-plan-
library
Discharge checklist
Follow up referral letter to GP
Copy of letter with patient (optional)
Current asthma action plan
Triggers identified
Medications prescribed including
Relievers-short acting B agonists
Preventers-steroids
Symptom controllers-long acting B agonists (if prescribed)
Ensure medications will last until arranged review
Spacer or other delivery systems available and patient
understands use and care
Asthma handouts given (patient information fact sheet)
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 httpwwwnationalasthmaorgauhealth-professionalstools-for-primary-careasthma-action-plansasthma-action-
plan-library
Example action plan
Emergency Department HMO education series
2012
Case B3
22 yo man
Brought to the ED by his partner
Gradual onset of SOB
Now present for few hours
What else do you want to know
Emergency Department HMO education series
2012
Further history amp examination
No wheeze
Productive cough
No recent URTI
Childhood asthma (age
3-12) hay fever
No cardiac history
No risk factors for PE
RR 34 HR 110 SR BP
8965
Sat 87 RA
Dull R base with coarse
crackles
Emergency Department HMO education series
2012
Investigations
The CXR is hellip
ABG on room air
pH 730 CO2 55
O2 70 HCO3 18
What do the blood gases
show
How severe is the
problem
Emergency Department HMO education series
2012
What scoring tools for
pneumonia
SMARTCOP CURB-65 Sepsis guidelines
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
SMARTCOP
SMARTCOP
SMARTCOP
CURB 65
Various website and apps can assist you in
remembering them wwwmdcalccom
Emergency Department HMO education series
2012
Case B4 - Female in her 60rsquos
Sudden onset SOB (present now for 1 hour quite
severe) right sided pleuritic chest pain
Mild fever
Right total knee replacement 3 days ago
persistent leg swelling since yesterday
Non-smoker
No previous cardiorespiratory disease
Emergency Department HMO education series
2012
What is the differential
diagnosis
Emergency Department HMO education series
2012
What is the differential
diagnosis
Most likely
PE
Next likely
Pneumonia
Less likely
Pneumothorax
Arrhythmia
AMI
Emergency Department HMO education series
2012
On examination amp tests
Tachypnoea and some WOB
RR 24 T 376 HR 110 BP 11070
Sats 93 RA
Chest clear with normal percussion and normal breath
sounds
CXR normal
ABG pH 75 CO2 30mmHg p02 62mmHg on RA
Most likely diagnosis
What are Wells criteria
What are Wells criteria
PERC
D-Dimer
What test do you want to do
Emergency Department HMO education series
2012
What can you see
Emergency Department HMO education series
2012
Filling defect R main pulmonary trunk
Emergency Department HMO education series
2012
Emergency Department HMO education series
2012
Case C Man in 60rsquos
Woke this am very SOB and distressed ndash called
ambulance
Progressive SOB over 6 months
Chronic cough
Usually with white sputum
Now worse with no change in sputum colour
No associated fever
SOB in night ndash gets up
Ankles swollen recently
Heavy smoker (35 pack years)
Admission to local hospital 612 ago with chest pains
Emergency Department HMO education series
2012
Differential diagnosis
CCF with acute exacerbation
Chronic obstructive pulmonary disease
(COPD) with acute infective exacerbation
Anaemia
Emergency Department HMO education series
2012
Exam amp investigationshellip
Unwell RR 36 T 368 HR 90 SR BP 180102
Satrsquos 88 RA
Evidence of work of breathing and use of accessory muscles (which are these)
Pursed lip breathing
Prolonged expiration with wheeze
ABG pH 728 pCO2 60 pO2 55 HCO3 26
What do these show
Do you want a CXR
Emergency Department HMO education series
2012
Emergency Department HMO education series
2012
Diagnosis
Acute cardiac failure ndash APO
Most likely cause
Treatment
ECG ndash filed unsigned and
unseen
Emergency Department HMO education series
2012
Diagnosis
Acute cardiac failure ndash APO
Most likely cause
Treatment
Emergency Department HMO education series
2012
Diagnosis - APO
Acute cardiac failure
Treatment
Medications Nitroglycerin SL topical or IV titrated to avoid hypotension Most rapidly
venodilates reduces LV afterload and corrects myocardial ischaemia
Frusemide IV Despite universal use absolute efficacy is unclear
Ventilatory Assistance Non-invasive ventilation (NIV) reduces mortality by 40 particularly with CPAP
and reduces need to intubate
Emergency Department HMO education series
2012
Case C2 - Male in 60rsquos
Progressive SOB over 6 months worse over 24 hours
Orthopnoea Paroxysmal nocturnal dyspnoea (PND) SOA All present to a minor degree over the 6 months but worse for 24 hours
Palpitations (last 24 hours)
Previous AMI 4 years ago pace maker
Ex-smoker Hypertension (HT) diabetes
Emergency Department HMO education series
2012
Examination
Unwell looking with increased work of breathing
RR 26 afeb HR Irreg 130 BP 10070
Sat 90 RA
JVP 5cm
SOA ++
Displaced apex beat no cardiac murmurs 3rd heart sound present
Normal chest expansion but stony dull percussion in the bases (RgtL) bilateral inspiratory crepitations just above the dull areas
ECG ndash what is your diagnosis
Emergency Department HMO education series
2012
Cardiac failure
Emergency Department HMO education series
2012
Case C2 - Summary
Long standing heart failure with an acute
exacerbation due to new onset rapid AF
Treatment of AF amp heart failure
Antithrombotic strategy
Then rate control
Perhaps rhythm control
See review article re AF treatment
To be published early 2013 Australian Rural Doctor
Case D
Mid 60s male
Found SOB ++ in street
Ambulance called
In ED
SOB at rest
Doesnt want help
Funny smell
Further information
Dishevelled
HR 120 reg BP 9560 Sats 94 RA
Vomiting intermittently
What will you do
Further treatment and
investigation
Further history from patient and collateral
sources
Resuscitation
IV access fluids
Bloods ndash FBC UEC CMP Blood gas
pH 71 pCO2 20 pO2 90 HCO3 10 BE -16
Further treatment and
investigation
Further history from patient and collateral
sources
Resuscitation
IV access fluids
Bloods ndash FBC UEC CMP Blood gas
pH 71 pCO2 20 pO2 90 HCO3 10 BE -16
BSL gt30
Further treatment and
investigation
Treatment
IV fluids ndash caution with Na and cerebral oedema
IV insulin
001 ndash 01 unitskghr
aim for BSL 2mmolL drop per hour
Continue until metabolic correction
Monitor and correct K+ other electrolytes
Monitor urine ketones VBGABG
Identify precipitant
Resolution
Wife arrives and is relieved to find husband
Chairman of Rotary Club
UTI developed whilst wife away for weekend
Questions
Summary
Diagnosis of the breathless patient requires you to look for clueshellip The time course of the illness
Associated symptoms
Known diseases or risk factors for disease
Treatment of illnesses supported by evidence for pneumonia asthma PE AF etc
Interpretation of radiology best done with clinical context
Thankyou
Emergency Department HMO education series
2012
What else should I ask
Travel historyhellip
Other important symptoms of respiratory
disease
Cough
Acute
Chronic
Haemoptysis (cancer TB other infections)
Chest Pain
Daytime sleepiness (obstructive sleep apnea)
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Emergency Department HMO education series
2013
Paediatrics
Cases
Emergency Department HMO education series
2013
Case A
2 yo presents to ED at 2200 with mother
Not distressed (child ndash mother anxious)
Stridor noted at triage
What is your differential
Emergency Department HMO education series
2013
What is your differential
Croup
FB
Epiglottitis
Upper airway massswelling
Functional
Emergency Department HMO education series
2013
Emergency Department HMO education series
2012
What else might you elicit in
the history
What else might you elicit in
the history Recent or current viral illness in child sibs or
kinderchild care
Similar events in the past
Immunisation history (How many doses of Hib and when)
Fluids and food intake
How parentcarer feels about behavior
Possible FB
Emergency Department HMO education series
2013
On review
Child becomes distressed when you
approach and attempt to examine
Remember
Emergency Department HMO education series
2013
Emergency Department HMO education series
2012
On review
Child becomes distressed when you
approach and attempt to examine
Emergency Department HMO education series
2012
On review
Child becomes distressed when you
approach and attempt to examine
St Gurnasty Infirmary Unpleasantshire Hospitals
Services Trust
Kill or be killed
On review
Child becomes distressed when you
approach and attempt to examine
Intercostal recession marked
Tracheal tug noted
Also note respiratory rate O2 requirements
Emergency Department HMO education series
2013
text
Croup
Emergency Department HMO education series
2013
Treatment
Steroids have been shown to decrease the length of hospital stay need for nebulised Adrenaline and
other interventions
Mild to Moderate Croup
Prednisolone 1mgkg AND prescribe a second dose for the next evening OR a single dose of
Oral Dexamethasone 015mgkg Observe for half an hour post steroid administration Discharge
once stridor-free at rest
Severe croup
Nebulised adrenaline (1 mL of 1 adrenaline diluted to 4 ml with Normal Saline or 5ml of adrenaline
11000)
AND
Give 06mgkg (max 12mg) IMIV dexamethasone
Emergency Department HMO education series
2013
Case B
22 yo man
Brought to the ED by his partner
Sudden onset of SOB
Now present for few hours
How is your differential diagnosis affected by
the sudden onset
Emergency Department HMO education series
2013
Further history
Previously well smokes 10 cigarettesday
Left sided chest pain
Moderate
Pleuritic
Started with the SOB
Is there anything else you would like to ask
What is your differential diagnosis
Emergency Department HMO education series
2013
Emergency Department HMO education series
2012
Differential diagnosis
Pneumothorax
Arrhythmia
Pulmonary Embolism
Asthma (less likely)
Pneumonia
Anxiety
Emergency Department HMO education series
2012
Differential diagnosis
Pneumothorax
Arrhythmia
Pulmonary Embolism
Asthma (less likely)
Pneumonia
Anxiety (Imagine that being your diagnosis and you missed a pound$^ your honour)
You horrible
little doctor
Emergency Department HMO education series
2012
Examination findings
Looks unwell quite distressed with WOB
RR 26 HR 125 SR BP 8060 afebrile
Saturation 93 RA (room air)
Trachea midline
chest expansion on the left
Hyper-resonant percussion note on the left
air entry left lung
What is going on
Is this serious
What is your immediate management
Emergency Department HMO education series
2012
Describe this CXR
Emergency Department HMO education series
2012
Describe this CXR
gt or lt 2cm
Where gt 2cm then pneumothorax is gt50 and is considered large
Emergency Department HMO education series
2012
Describe this CXR
Bigger image next slide
Tethered
lung
gt2cm
Right shift of
mediastinum
Air next to
pericardium
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)
Tension
bullLarge bore cannula 2nd intercostal space mid-clavicular line
If large non-tension
bullgt2cm rim (ie gt50)
bull14-18 G cannula safe triangle (or 2ICS if contraindicated) - aspirate
bullDrain 8-14 FG is usually adequate although 28 FG may be required with
mechanical ventilation
Other considerations
bullNo improvement with drain ndash suction cardiothoracic involvement
httpthoraxbmjcomcontent58suppl_2ii39full
httpssecurecollemergencymedacukcodedocumentaspID=6194
Describe the treatment for
Pneumothorax
httpwwwbrit-thoracicorgukPortals0GuidelinesPleuralDiseaseGuidelinesPleural20Guideline202010Pleural20disease20201020pneumothoraxpdf
Emergency Department HMO education series
2012
Case B2
22 yo 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
Emergency Department HMO education series
2012
Further history amp 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
11070
Sat 97 RA
Widespread wheeze
(what causes this
sound)
Emergency Department HMO education series
2012
Investigations
If the CXR is normal (ish)hellip
Peak Flow 250min (how does this help us)
ABG on room air pH 75 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
Emergency Department HMO education series
2012
Investigations
If the CXR is normalhellip
Peak Flow 250min (how does this help us)
ABG on room air pH 75 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
Emergency Department HMO education series
2012
BBH Asthma protocol
Emergency Department HMO education series
2012
Investigations
If the CXR is normalhellip
Peak Flow 250min (how does this help us)
ABG on room air pH 75 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
Emergency Department HMO education series
2012
Investigations
If the CXR is normalhellip
Peak Flow 300min (how does this help us)
ABG on room air pH 75 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
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 httpwwwnationalasthmaorgauhealth-professionalstools-for-primary-careasthma-action-plansasthma-action-
plan-library
Asthma sticker
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 httpwwwnationalasthmaorgauhealth-professionalstools-for-primary-careasthma-action-plansasthma-action-plan-
library
Discharge checklist
Follow up referral letter to GP
Copy of letter with patient (optional)
Current asthma action plan
Triggers identified
Medications prescribed including
Relievers-short acting B agonists
Preventers-steroids
Symptom controllers-long acting B agonists (if prescribed)
Ensure medications will last until arranged review
Spacer or other delivery systems available and patient
understands use and care
Asthma handouts given (patient information fact sheet)
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 httpwwwnationalasthmaorgauhealth-professionalstools-for-primary-careasthma-action-plansasthma-action-
plan-library
Example action plan
Emergency Department HMO education series
2012
Case B3
22 yo man
Brought to the ED by his partner
Gradual onset of SOB
Now present for few hours
What else do you want to know
Emergency Department HMO education series
2012
Further history amp examination
No wheeze
Productive cough
No recent URTI
Childhood asthma (age
3-12) hay fever
No cardiac history
No risk factors for PE
RR 34 HR 110 SR BP
8965
Sat 87 RA
Dull R base with coarse
crackles
Emergency Department HMO education series
2012
Investigations
The CXR is hellip
ABG on room air
pH 730 CO2 55
O2 70 HCO3 18
What do the blood gases
show
How severe is the
problem
Emergency Department HMO education series
2012
What scoring tools for
pneumonia
SMARTCOP CURB-65 Sepsis guidelines
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
SMARTCOP
SMARTCOP
SMARTCOP
CURB 65
Various website and apps can assist you in
remembering them wwwmdcalccom
Emergency Department HMO education series
2012
Case B4 - Female in her 60rsquos
Sudden onset SOB (present now for 1 hour quite
severe) right sided pleuritic chest pain
Mild fever
Right total knee replacement 3 days ago
persistent leg swelling since yesterday
Non-smoker
No previous cardiorespiratory disease
Emergency Department HMO education series
2012
What is the differential
diagnosis
Emergency Department HMO education series
2012
What is the differential
diagnosis
Most likely
PE
Next likely
Pneumonia
Less likely
Pneumothorax
Arrhythmia
AMI
Emergency Department HMO education series
2012
On examination amp tests
Tachypnoea and some WOB
RR 24 T 376 HR 110 BP 11070
Sats 93 RA
Chest clear with normal percussion and normal breath
sounds
CXR normal
ABG pH 75 CO2 30mmHg p02 62mmHg on RA
Most likely diagnosis
What are Wells criteria
What are Wells criteria
PERC
D-Dimer
What test do you want to do
Emergency Department HMO education series
2012
What can you see
Emergency Department HMO education series
2012
Filling defect R main pulmonary trunk
Emergency Department HMO education series
2012
Emergency Department HMO education series
2012
Case C Man in 60rsquos
Woke this am very SOB and distressed ndash called
ambulance
Progressive SOB over 6 months
Chronic cough
Usually with white sputum
Now worse with no change in sputum colour
No associated fever
SOB in night ndash gets up
Ankles swollen recently
Heavy smoker (35 pack years)
Admission to local hospital 612 ago with chest pains
Emergency Department HMO education series
2012
Differential diagnosis
CCF with acute exacerbation
Chronic obstructive pulmonary disease
(COPD) with acute infective exacerbation
Anaemia
Emergency Department HMO education series
2012
Exam amp investigationshellip
Unwell RR 36 T 368 HR 90 SR BP 180102
Satrsquos 88 RA
Evidence of work of breathing and use of accessory muscles (which are these)
Pursed lip breathing
Prolonged expiration with wheeze
ABG pH 728 pCO2 60 pO2 55 HCO3 26
What do these show
Do you want a CXR
Emergency Department HMO education series
2012
Emergency Department HMO education series
2012
Diagnosis
Acute cardiac failure ndash APO
Most likely cause
Treatment
ECG ndash filed unsigned and
unseen
Emergency Department HMO education series
2012
Diagnosis
Acute cardiac failure ndash APO
Most likely cause
Treatment
Emergency Department HMO education series
2012
Diagnosis - APO
Acute cardiac failure
Treatment
Medications Nitroglycerin SL topical or IV titrated to avoid hypotension Most rapidly
venodilates reduces LV afterload and corrects myocardial ischaemia
Frusemide IV Despite universal use absolute efficacy is unclear
Ventilatory Assistance Non-invasive ventilation (NIV) reduces mortality by 40 particularly with CPAP
and reduces need to intubate
Emergency Department HMO education series
2012
Case C2 - Male in 60rsquos
Progressive SOB over 6 months worse over 24 hours
Orthopnoea Paroxysmal nocturnal dyspnoea (PND) SOA All present to a minor degree over the 6 months but worse for 24 hours
Palpitations (last 24 hours)
Previous AMI 4 years ago pace maker
Ex-smoker Hypertension (HT) diabetes
Emergency Department HMO education series
2012
Examination
Unwell looking with increased work of breathing
RR 26 afeb HR Irreg 130 BP 10070
Sat 90 RA
JVP 5cm
SOA ++
Displaced apex beat no cardiac murmurs 3rd heart sound present
Normal chest expansion but stony dull percussion in the bases (RgtL) bilateral inspiratory crepitations just above the dull areas
ECG ndash what is your diagnosis
Emergency Department HMO education series
2012
Cardiac failure
Emergency Department HMO education series
2012
Case C2 - Summary
Long standing heart failure with an acute
exacerbation due to new onset rapid AF
Treatment of AF amp heart failure
Antithrombotic strategy
Then rate control
Perhaps rhythm control
See review article re AF treatment
To be published early 2013 Australian Rural Doctor
Case D
Mid 60s male
Found SOB ++ in street
Ambulance called
In ED
SOB at rest
Doesnt want help
Funny smell
Further information
Dishevelled
HR 120 reg BP 9560 Sats 94 RA
Vomiting intermittently
What will you do
Further treatment and
investigation
Further history from patient and collateral
sources
Resuscitation
IV access fluids
Bloods ndash FBC UEC CMP Blood gas
pH 71 pCO2 20 pO2 90 HCO3 10 BE -16
Further treatment and
investigation
Further history from patient and collateral
sources
Resuscitation
IV access fluids
Bloods ndash FBC UEC CMP Blood gas
pH 71 pCO2 20 pO2 90 HCO3 10 BE -16
BSL gt30
Further treatment and
investigation
Treatment
IV fluids ndash caution with Na and cerebral oedema
IV insulin
001 ndash 01 unitskghr
aim for BSL 2mmolL drop per hour
Continue until metabolic correction
Monitor and correct K+ other electrolytes
Monitor urine ketones VBGABG
Identify precipitant
Resolution
Wife arrives and is relieved to find husband
Chairman of Rotary Club
UTI developed whilst wife away for weekend
Questions
Summary
Diagnosis of the breathless patient requires you to look for clueshellip The time course of the illness
Associated symptoms
Known diseases or risk factors for disease
Treatment of illnesses supported by evidence for pneumonia asthma PE AF etc
Interpretation of radiology best done with clinical context
Thankyou
Emergency Department HMO education series
2012
What else should I ask
Travel historyhellip
Other important symptoms of respiratory
disease
Cough
Acute
Chronic
Haemoptysis (cancer TB other infections)
Chest Pain
Daytime sleepiness (obstructive sleep apnea)
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Cases
Emergency Department HMO education series
2013
Case A
2 yo presents to ED at 2200 with mother
Not distressed (child ndash mother anxious)
Stridor noted at triage
What is your differential
Emergency Department HMO education series
2013
What is your differential
Croup
FB
Epiglottitis
Upper airway massswelling
Functional
Emergency Department HMO education series
2013
Emergency Department HMO education series
2012
What else might you elicit in
the history
What else might you elicit in
the history Recent or current viral illness in child sibs or
kinderchild care
Similar events in the past
Immunisation history (How many doses of Hib and when)
Fluids and food intake
How parentcarer feels about behavior
Possible FB
Emergency Department HMO education series
2013
On review
Child becomes distressed when you
approach and attempt to examine
Remember
Emergency Department HMO education series
2013
Emergency Department HMO education series
2012
On review
Child becomes distressed when you
approach and attempt to examine
Emergency Department HMO education series
2012
On review
Child becomes distressed when you
approach and attempt to examine
St Gurnasty Infirmary Unpleasantshire Hospitals
Services Trust
Kill or be killed
On review
Child becomes distressed when you
approach and attempt to examine
Intercostal recession marked
Tracheal tug noted
Also note respiratory rate O2 requirements
Emergency Department HMO education series
2013
text
Croup
Emergency Department HMO education series
2013
Treatment
Steroids have been shown to decrease the length of hospital stay need for nebulised Adrenaline and
other interventions
Mild to Moderate Croup
Prednisolone 1mgkg AND prescribe a second dose for the next evening OR a single dose of
Oral Dexamethasone 015mgkg Observe for half an hour post steroid administration Discharge
once stridor-free at rest
Severe croup
Nebulised adrenaline (1 mL of 1 adrenaline diluted to 4 ml with Normal Saline or 5ml of adrenaline
11000)
AND
Give 06mgkg (max 12mg) IMIV dexamethasone
Emergency Department HMO education series
2013
Case B
22 yo man
Brought to the ED by his partner
Sudden onset of SOB
Now present for few hours
How is your differential diagnosis affected by
the sudden onset
Emergency Department HMO education series
2013
Further history
Previously well smokes 10 cigarettesday
Left sided chest pain
Moderate
Pleuritic
Started with the SOB
Is there anything else you would like to ask
What is your differential diagnosis
Emergency Department HMO education series
2013
Emergency Department HMO education series
2012
Differential diagnosis
Pneumothorax
Arrhythmia
Pulmonary Embolism
Asthma (less likely)
Pneumonia
Anxiety
Emergency Department HMO education series
2012
Differential diagnosis
Pneumothorax
Arrhythmia
Pulmonary Embolism
Asthma (less likely)
Pneumonia
Anxiety (Imagine that being your diagnosis and you missed a pound$^ your honour)
You horrible
little doctor
Emergency Department HMO education series
2012
Examination findings
Looks unwell quite distressed with WOB
RR 26 HR 125 SR BP 8060 afebrile
Saturation 93 RA (room air)
Trachea midline
chest expansion on the left
Hyper-resonant percussion note on the left
air entry left lung
What is going on
Is this serious
What is your immediate management
Emergency Department HMO education series
2012
Describe this CXR
Emergency Department HMO education series
2012
Describe this CXR
gt or lt 2cm
Where gt 2cm then pneumothorax is gt50 and is considered large
Emergency Department HMO education series
2012
Describe this CXR
Bigger image next slide
Tethered
lung
gt2cm
Right shift of
mediastinum
Air next to
pericardium
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)
Tension
bullLarge bore cannula 2nd intercostal space mid-clavicular line
If large non-tension
bullgt2cm rim (ie gt50)
bull14-18 G cannula safe triangle (or 2ICS if contraindicated) - aspirate
bullDrain 8-14 FG is usually adequate although 28 FG may be required with
mechanical ventilation
Other considerations
bullNo improvement with drain ndash suction cardiothoracic involvement
httpthoraxbmjcomcontent58suppl_2ii39full
httpssecurecollemergencymedacukcodedocumentaspID=6194
Describe the treatment for
Pneumothorax
httpwwwbrit-thoracicorgukPortals0GuidelinesPleuralDiseaseGuidelinesPleural20Guideline202010Pleural20disease20201020pneumothoraxpdf
Emergency Department HMO education series
2012
Case B2
22 yo 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
Emergency Department HMO education series
2012
Further history amp 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
11070
Sat 97 RA
Widespread wheeze
(what causes this
sound)
Emergency Department HMO education series
2012
Investigations
If the CXR is normal (ish)hellip
Peak Flow 250min (how does this help us)
ABG on room air pH 75 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
Emergency Department HMO education series
2012
Investigations
If the CXR is normalhellip
Peak Flow 250min (how does this help us)
ABG on room air pH 75 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
Emergency Department HMO education series
2012
BBH Asthma protocol
Emergency Department HMO education series
2012
Investigations
If the CXR is normalhellip
Peak Flow 250min (how does this help us)
ABG on room air pH 75 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
Emergency Department HMO education series
2012
Investigations
If the CXR is normalhellip
Peak Flow 300min (how does this help us)
ABG on room air pH 75 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
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 httpwwwnationalasthmaorgauhealth-professionalstools-for-primary-careasthma-action-plansasthma-action-
plan-library
Asthma sticker
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 httpwwwnationalasthmaorgauhealth-professionalstools-for-primary-careasthma-action-plansasthma-action-plan-
library
Discharge checklist
Follow up referral letter to GP
Copy of letter with patient (optional)
Current asthma action plan
Triggers identified
Medications prescribed including
Relievers-short acting B agonists
Preventers-steroids
Symptom controllers-long acting B agonists (if prescribed)
Ensure medications will last until arranged review
Spacer or other delivery systems available and patient
understands use and care
Asthma handouts given (patient information fact sheet)
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 httpwwwnationalasthmaorgauhealth-professionalstools-for-primary-careasthma-action-plansasthma-action-
plan-library
Example action plan
Emergency Department HMO education series
2012
Case B3
22 yo man
Brought to the ED by his partner
Gradual onset of SOB
Now present for few hours
What else do you want to know
Emergency Department HMO education series
2012
Further history amp examination
No wheeze
Productive cough
No recent URTI
Childhood asthma (age
3-12) hay fever
No cardiac history
No risk factors for PE
RR 34 HR 110 SR BP
8965
Sat 87 RA
Dull R base with coarse
crackles
Emergency Department HMO education series
2012
Investigations
The CXR is hellip
ABG on room air
pH 730 CO2 55
O2 70 HCO3 18
What do the blood gases
show
How severe is the
problem
Emergency Department HMO education series
2012
What scoring tools for
pneumonia
SMARTCOP CURB-65 Sepsis guidelines
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
SMARTCOP
SMARTCOP
SMARTCOP
CURB 65
Various website and apps can assist you in
remembering them wwwmdcalccom
Emergency Department HMO education series
2012
Case B4 - Female in her 60rsquos
Sudden onset SOB (present now for 1 hour quite
severe) right sided pleuritic chest pain
Mild fever
Right total knee replacement 3 days ago
persistent leg swelling since yesterday
Non-smoker
No previous cardiorespiratory disease
Emergency Department HMO education series
2012
What is the differential
diagnosis
Emergency Department HMO education series
2012
What is the differential
diagnosis
Most likely
PE
Next likely
Pneumonia
Less likely
Pneumothorax
Arrhythmia
AMI
Emergency Department HMO education series
2012
On examination amp tests
Tachypnoea and some WOB
RR 24 T 376 HR 110 BP 11070
Sats 93 RA
Chest clear with normal percussion and normal breath
sounds
CXR normal
ABG pH 75 CO2 30mmHg p02 62mmHg on RA
Most likely diagnosis
What are Wells criteria
What are Wells criteria
PERC
D-Dimer
What test do you want to do
Emergency Department HMO education series
2012
What can you see
Emergency Department HMO education series
2012
Filling defect R main pulmonary trunk
Emergency Department HMO education series
2012
Emergency Department HMO education series
2012
Case C Man in 60rsquos
Woke this am very SOB and distressed ndash called
ambulance
Progressive SOB over 6 months
Chronic cough
Usually with white sputum
Now worse with no change in sputum colour
No associated fever
SOB in night ndash gets up
Ankles swollen recently
Heavy smoker (35 pack years)
Admission to local hospital 612 ago with chest pains
Emergency Department HMO education series
2012
Differential diagnosis
CCF with acute exacerbation
Chronic obstructive pulmonary disease
(COPD) with acute infective exacerbation
Anaemia
Emergency Department HMO education series
2012
Exam amp investigationshellip
Unwell RR 36 T 368 HR 90 SR BP 180102
Satrsquos 88 RA
Evidence of work of breathing and use of accessory muscles (which are these)
Pursed lip breathing
Prolonged expiration with wheeze
ABG pH 728 pCO2 60 pO2 55 HCO3 26
What do these show
Do you want a CXR
Emergency Department HMO education series
2012
Emergency Department HMO education series
2012
Diagnosis
Acute cardiac failure ndash APO
Most likely cause
Treatment
ECG ndash filed unsigned and
unseen
Emergency Department HMO education series
2012
Diagnosis
Acute cardiac failure ndash APO
Most likely cause
Treatment
Emergency Department HMO education series
2012
Diagnosis - APO
Acute cardiac failure
Treatment
Medications Nitroglycerin SL topical or IV titrated to avoid hypotension Most rapidly
venodilates reduces LV afterload and corrects myocardial ischaemia
Frusemide IV Despite universal use absolute efficacy is unclear
Ventilatory Assistance Non-invasive ventilation (NIV) reduces mortality by 40 particularly with CPAP
and reduces need to intubate
Emergency Department HMO education series
2012
Case C2 - Male in 60rsquos
Progressive SOB over 6 months worse over 24 hours
Orthopnoea Paroxysmal nocturnal dyspnoea (PND) SOA All present to a minor degree over the 6 months but worse for 24 hours
Palpitations (last 24 hours)
Previous AMI 4 years ago pace maker
Ex-smoker Hypertension (HT) diabetes
Emergency Department HMO education series
2012
Examination
Unwell looking with increased work of breathing
RR 26 afeb HR Irreg 130 BP 10070
Sat 90 RA
JVP 5cm
SOA ++
Displaced apex beat no cardiac murmurs 3rd heart sound present
Normal chest expansion but stony dull percussion in the bases (RgtL) bilateral inspiratory crepitations just above the dull areas
ECG ndash what is your diagnosis
Emergency Department HMO education series
2012
Cardiac failure
Emergency Department HMO education series
2012
Case C2 - Summary
Long standing heart failure with an acute
exacerbation due to new onset rapid AF
Treatment of AF amp heart failure
Antithrombotic strategy
Then rate control
Perhaps rhythm control
See review article re AF treatment
To be published early 2013 Australian Rural Doctor
Case D
Mid 60s male
Found SOB ++ in street
Ambulance called
In ED
SOB at rest
Doesnt want help
Funny smell
Further information
Dishevelled
HR 120 reg BP 9560 Sats 94 RA
Vomiting intermittently
What will you do
Further treatment and
investigation
Further history from patient and collateral
sources
Resuscitation
IV access fluids
Bloods ndash FBC UEC CMP Blood gas
pH 71 pCO2 20 pO2 90 HCO3 10 BE -16
Further treatment and
investigation
Further history from patient and collateral
sources
Resuscitation
IV access fluids
Bloods ndash FBC UEC CMP Blood gas
pH 71 pCO2 20 pO2 90 HCO3 10 BE -16
BSL gt30
Further treatment and
investigation
Treatment
IV fluids ndash caution with Na and cerebral oedema
IV insulin
001 ndash 01 unitskghr
aim for BSL 2mmolL drop per hour
Continue until metabolic correction
Monitor and correct K+ other electrolytes
Monitor urine ketones VBGABG
Identify precipitant
Resolution
Wife arrives and is relieved to find husband
Chairman of Rotary Club
UTI developed whilst wife away for weekend
Questions
Summary
Diagnosis of the breathless patient requires you to look for clueshellip The time course of the illness
Associated symptoms
Known diseases or risk factors for disease
Treatment of illnesses supported by evidence for pneumonia asthma PE AF etc
Interpretation of radiology best done with clinical context
Thankyou
Emergency Department HMO education series
2012
What else should I ask
Travel historyhellip
Other important symptoms of respiratory
disease
Cough
Acute
Chronic
Haemoptysis (cancer TB other infections)
Chest Pain
Daytime sleepiness (obstructive sleep apnea)
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Emergency Department HMO education series
2013
Case A
2 yo presents to ED at 2200 with mother
Not distressed (child ndash mother anxious)
Stridor noted at triage
What is your differential
Emergency Department HMO education series
2013
What is your differential
Croup
FB
Epiglottitis
Upper airway massswelling
Functional
Emergency Department HMO education series
2013
Emergency Department HMO education series
2012
What else might you elicit in
the history
What else might you elicit in
the history Recent or current viral illness in child sibs or
kinderchild care
Similar events in the past
Immunisation history (How many doses of Hib and when)
Fluids and food intake
How parentcarer feels about behavior
Possible FB
Emergency Department HMO education series
2013
On review
Child becomes distressed when you
approach and attempt to examine
Remember
Emergency Department HMO education series
2013
Emergency Department HMO education series
2012
On review
Child becomes distressed when you
approach and attempt to examine
Emergency Department HMO education series
2012
On review
Child becomes distressed when you
approach and attempt to examine
St Gurnasty Infirmary Unpleasantshire Hospitals
Services Trust
Kill or be killed
On review
Child becomes distressed when you
approach and attempt to examine
Intercostal recession marked
Tracheal tug noted
Also note respiratory rate O2 requirements
Emergency Department HMO education series
2013
text
Croup
Emergency Department HMO education series
2013
Treatment
Steroids have been shown to decrease the length of hospital stay need for nebulised Adrenaline and
other interventions
Mild to Moderate Croup
Prednisolone 1mgkg AND prescribe a second dose for the next evening OR a single dose of
Oral Dexamethasone 015mgkg Observe for half an hour post steroid administration Discharge
once stridor-free at rest
Severe croup
Nebulised adrenaline (1 mL of 1 adrenaline diluted to 4 ml with Normal Saline or 5ml of adrenaline
11000)
AND
Give 06mgkg (max 12mg) IMIV dexamethasone
Emergency Department HMO education series
2013
Case B
22 yo man
Brought to the ED by his partner
Sudden onset of SOB
Now present for few hours
How is your differential diagnosis affected by
the sudden onset
Emergency Department HMO education series
2013
Further history
Previously well smokes 10 cigarettesday
Left sided chest pain
Moderate
Pleuritic
Started with the SOB
Is there anything else you would like to ask
What is your differential diagnosis
Emergency Department HMO education series
2013
Emergency Department HMO education series
2012
Differential diagnosis
Pneumothorax
Arrhythmia
Pulmonary Embolism
Asthma (less likely)
Pneumonia
Anxiety
Emergency Department HMO education series
2012
Differential diagnosis
Pneumothorax
Arrhythmia
Pulmonary Embolism
Asthma (less likely)
Pneumonia
Anxiety (Imagine that being your diagnosis and you missed a pound$^ your honour)
You horrible
little doctor
Emergency Department HMO education series
2012
Examination findings
Looks unwell quite distressed with WOB
RR 26 HR 125 SR BP 8060 afebrile
Saturation 93 RA (room air)
Trachea midline
chest expansion on the left
Hyper-resonant percussion note on the left
air entry left lung
What is going on
Is this serious
What is your immediate management
Emergency Department HMO education series
2012
Describe this CXR
Emergency Department HMO education series
2012
Describe this CXR
gt or lt 2cm
Where gt 2cm then pneumothorax is gt50 and is considered large
Emergency Department HMO education series
2012
Describe this CXR
Bigger image next slide
Tethered
lung
gt2cm
Right shift of
mediastinum
Air next to
pericardium
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)
Tension
bullLarge bore cannula 2nd intercostal space mid-clavicular line
If large non-tension
bullgt2cm rim (ie gt50)
bull14-18 G cannula safe triangle (or 2ICS if contraindicated) - aspirate
bullDrain 8-14 FG is usually adequate although 28 FG may be required with
mechanical ventilation
Other considerations
bullNo improvement with drain ndash suction cardiothoracic involvement
httpthoraxbmjcomcontent58suppl_2ii39full
httpssecurecollemergencymedacukcodedocumentaspID=6194
Describe the treatment for
Pneumothorax
httpwwwbrit-thoracicorgukPortals0GuidelinesPleuralDiseaseGuidelinesPleural20Guideline202010Pleural20disease20201020pneumothoraxpdf
Emergency Department HMO education series
2012
Case B2
22 yo 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
Emergency Department HMO education series
2012
Further history amp 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
11070
Sat 97 RA
Widespread wheeze
(what causes this
sound)
Emergency Department HMO education series
2012
Investigations
If the CXR is normal (ish)hellip
Peak Flow 250min (how does this help us)
ABG on room air pH 75 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
Emergency Department HMO education series
2012
Investigations
If the CXR is normalhellip
Peak Flow 250min (how does this help us)
ABG on room air pH 75 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
Emergency Department HMO education series
2012
BBH Asthma protocol
Emergency Department HMO education series
2012
Investigations
If the CXR is normalhellip
Peak Flow 250min (how does this help us)
ABG on room air pH 75 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
Emergency Department HMO education series
2012
Investigations
If the CXR is normalhellip
Peak Flow 300min (how does this help us)
ABG on room air pH 75 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
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 httpwwwnationalasthmaorgauhealth-professionalstools-for-primary-careasthma-action-plansasthma-action-
plan-library
Asthma sticker
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 httpwwwnationalasthmaorgauhealth-professionalstools-for-primary-careasthma-action-plansasthma-action-plan-
library
Discharge checklist
Follow up referral letter to GP
Copy of letter with patient (optional)
Current asthma action plan
Triggers identified
Medications prescribed including
Relievers-short acting B agonists
Preventers-steroids
Symptom controllers-long acting B agonists (if prescribed)
Ensure medications will last until arranged review
Spacer or other delivery systems available and patient
understands use and care
Asthma handouts given (patient information fact sheet)
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 httpwwwnationalasthmaorgauhealth-professionalstools-for-primary-careasthma-action-plansasthma-action-
plan-library
Example action plan
Emergency Department HMO education series
2012
Case B3
22 yo man
Brought to the ED by his partner
Gradual onset of SOB
Now present for few hours
What else do you want to know
Emergency Department HMO education series
2012
Further history amp examination
No wheeze
Productive cough
No recent URTI
Childhood asthma (age
3-12) hay fever
No cardiac history
No risk factors for PE
RR 34 HR 110 SR BP
8965
Sat 87 RA
Dull R base with coarse
crackles
Emergency Department HMO education series
2012
Investigations
The CXR is hellip
ABG on room air
pH 730 CO2 55
O2 70 HCO3 18
What do the blood gases
show
How severe is the
problem
Emergency Department HMO education series
2012
What scoring tools for
pneumonia
SMARTCOP CURB-65 Sepsis guidelines
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
SMARTCOP
SMARTCOP
SMARTCOP
CURB 65
Various website and apps can assist you in
remembering them wwwmdcalccom
Emergency Department HMO education series
2012
Case B4 - Female in her 60rsquos
Sudden onset SOB (present now for 1 hour quite
severe) right sided pleuritic chest pain
Mild fever
Right total knee replacement 3 days ago
persistent leg swelling since yesterday
Non-smoker
No previous cardiorespiratory disease
Emergency Department HMO education series
2012
What is the differential
diagnosis
Emergency Department HMO education series
2012
What is the differential
diagnosis
Most likely
PE
Next likely
Pneumonia
Less likely
Pneumothorax
Arrhythmia
AMI
Emergency Department HMO education series
2012
On examination amp tests
Tachypnoea and some WOB
RR 24 T 376 HR 110 BP 11070
Sats 93 RA
Chest clear with normal percussion and normal breath
sounds
CXR normal
ABG pH 75 CO2 30mmHg p02 62mmHg on RA
Most likely diagnosis
What are Wells criteria
What are Wells criteria
PERC
D-Dimer
What test do you want to do
Emergency Department HMO education series
2012
What can you see
Emergency Department HMO education series
2012
Filling defect R main pulmonary trunk
Emergency Department HMO education series
2012
Emergency Department HMO education series
2012
Case C Man in 60rsquos
Woke this am very SOB and distressed ndash called
ambulance
Progressive SOB over 6 months
Chronic cough
Usually with white sputum
Now worse with no change in sputum colour
No associated fever
SOB in night ndash gets up
Ankles swollen recently
Heavy smoker (35 pack years)
Admission to local hospital 612 ago with chest pains
Emergency Department HMO education series
2012
Differential diagnosis
CCF with acute exacerbation
Chronic obstructive pulmonary disease
(COPD) with acute infective exacerbation
Anaemia
Emergency Department HMO education series
2012
Exam amp investigationshellip
Unwell RR 36 T 368 HR 90 SR BP 180102
Satrsquos 88 RA
Evidence of work of breathing and use of accessory muscles (which are these)
Pursed lip breathing
Prolonged expiration with wheeze
ABG pH 728 pCO2 60 pO2 55 HCO3 26
What do these show
Do you want a CXR
Emergency Department HMO education series
2012
Emergency Department HMO education series
2012
Diagnosis
Acute cardiac failure ndash APO
Most likely cause
Treatment
ECG ndash filed unsigned and
unseen
Emergency Department HMO education series
2012
Diagnosis
Acute cardiac failure ndash APO
Most likely cause
Treatment
Emergency Department HMO education series
2012
Diagnosis - APO
Acute cardiac failure
Treatment
Medications Nitroglycerin SL topical or IV titrated to avoid hypotension Most rapidly
venodilates reduces LV afterload and corrects myocardial ischaemia
Frusemide IV Despite universal use absolute efficacy is unclear
Ventilatory Assistance Non-invasive ventilation (NIV) reduces mortality by 40 particularly with CPAP
and reduces need to intubate
Emergency Department HMO education series
2012
Case C2 - Male in 60rsquos
Progressive SOB over 6 months worse over 24 hours
Orthopnoea Paroxysmal nocturnal dyspnoea (PND) SOA All present to a minor degree over the 6 months but worse for 24 hours
Palpitations (last 24 hours)
Previous AMI 4 years ago pace maker
Ex-smoker Hypertension (HT) diabetes
Emergency Department HMO education series
2012
Examination
Unwell looking with increased work of breathing
RR 26 afeb HR Irreg 130 BP 10070
Sat 90 RA
JVP 5cm
SOA ++
Displaced apex beat no cardiac murmurs 3rd heart sound present
Normal chest expansion but stony dull percussion in the bases (RgtL) bilateral inspiratory crepitations just above the dull areas
ECG ndash what is your diagnosis
Emergency Department HMO education series
2012
Cardiac failure
Emergency Department HMO education series
2012
Case C2 - Summary
Long standing heart failure with an acute
exacerbation due to new onset rapid AF
Treatment of AF amp heart failure
Antithrombotic strategy
Then rate control
Perhaps rhythm control
See review article re AF treatment
To be published early 2013 Australian Rural Doctor
Case D
Mid 60s male
Found SOB ++ in street
Ambulance called
In ED
SOB at rest
Doesnt want help
Funny smell
Further information
Dishevelled
HR 120 reg BP 9560 Sats 94 RA
Vomiting intermittently
What will you do
Further treatment and
investigation
Further history from patient and collateral
sources
Resuscitation
IV access fluids
Bloods ndash FBC UEC CMP Blood gas
pH 71 pCO2 20 pO2 90 HCO3 10 BE -16
Further treatment and
investigation
Further history from patient and collateral
sources
Resuscitation
IV access fluids
Bloods ndash FBC UEC CMP Blood gas
pH 71 pCO2 20 pO2 90 HCO3 10 BE -16
BSL gt30
Further treatment and
investigation
Treatment
IV fluids ndash caution with Na and cerebral oedema
IV insulin
001 ndash 01 unitskghr
aim for BSL 2mmolL drop per hour
Continue until metabolic correction
Monitor and correct K+ other electrolytes
Monitor urine ketones VBGABG
Identify precipitant
Resolution
Wife arrives and is relieved to find husband
Chairman of Rotary Club
UTI developed whilst wife away for weekend
Questions
Summary
Diagnosis of the breathless patient requires you to look for clueshellip The time course of the illness
Associated symptoms
Known diseases or risk factors for disease
Treatment of illnesses supported by evidence for pneumonia asthma PE AF etc
Interpretation of radiology best done with clinical context
Thankyou
Emergency Department HMO education series
2012
What else should I ask
Travel historyhellip
Other important symptoms of respiratory
disease
Cough
Acute
Chronic
Haemoptysis (cancer TB other infections)
Chest Pain
Daytime sleepiness (obstructive sleep apnea)
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
What is your differential
Emergency Department HMO education series
2013
What is your differential
Croup
FB
Epiglottitis
Upper airway massswelling
Functional
Emergency Department HMO education series
2013
Emergency Department HMO education series
2012
What else might you elicit in
the history
What else might you elicit in
the history Recent or current viral illness in child sibs or
kinderchild care
Similar events in the past
Immunisation history (How many doses of Hib and when)
Fluids and food intake
How parentcarer feels about behavior
Possible FB
Emergency Department HMO education series
2013
On review
Child becomes distressed when you
approach and attempt to examine
Remember
Emergency Department HMO education series
2013
Emergency Department HMO education series
2012
On review
Child becomes distressed when you
approach and attempt to examine
Emergency Department HMO education series
2012
On review
Child becomes distressed when you
approach and attempt to examine
St Gurnasty Infirmary Unpleasantshire Hospitals
Services Trust
Kill or be killed
On review
Child becomes distressed when you
approach and attempt to examine
Intercostal recession marked
Tracheal tug noted
Also note respiratory rate O2 requirements
Emergency Department HMO education series
2013
text
Croup
Emergency Department HMO education series
2013
Treatment
Steroids have been shown to decrease the length of hospital stay need for nebulised Adrenaline and
other interventions
Mild to Moderate Croup
Prednisolone 1mgkg AND prescribe a second dose for the next evening OR a single dose of
Oral Dexamethasone 015mgkg Observe for half an hour post steroid administration Discharge
once stridor-free at rest
Severe croup
Nebulised adrenaline (1 mL of 1 adrenaline diluted to 4 ml with Normal Saline or 5ml of adrenaline
11000)
AND
Give 06mgkg (max 12mg) IMIV dexamethasone
Emergency Department HMO education series
2013
Case B
22 yo man
Brought to the ED by his partner
Sudden onset of SOB
Now present for few hours
How is your differential diagnosis affected by
the sudden onset
Emergency Department HMO education series
2013
Further history
Previously well smokes 10 cigarettesday
Left sided chest pain
Moderate
Pleuritic
Started with the SOB
Is there anything else you would like to ask
What is your differential diagnosis
Emergency Department HMO education series
2013
Emergency Department HMO education series
2012
Differential diagnosis
Pneumothorax
Arrhythmia
Pulmonary Embolism
Asthma (less likely)
Pneumonia
Anxiety
Emergency Department HMO education series
2012
Differential diagnosis
Pneumothorax
Arrhythmia
Pulmonary Embolism
Asthma (less likely)
Pneumonia
Anxiety (Imagine that being your diagnosis and you missed a pound$^ your honour)
You horrible
little doctor
Emergency Department HMO education series
2012
Examination findings
Looks unwell quite distressed with WOB
RR 26 HR 125 SR BP 8060 afebrile
Saturation 93 RA (room air)
Trachea midline
chest expansion on the left
Hyper-resonant percussion note on the left
air entry left lung
What is going on
Is this serious
What is your immediate management
Emergency Department HMO education series
2012
Describe this CXR
Emergency Department HMO education series
2012
Describe this CXR
gt or lt 2cm
Where gt 2cm then pneumothorax is gt50 and is considered large
Emergency Department HMO education series
2012
Describe this CXR
Bigger image next slide
Tethered
lung
gt2cm
Right shift of
mediastinum
Air next to
pericardium
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)
Tension
bullLarge bore cannula 2nd intercostal space mid-clavicular line
If large non-tension
bullgt2cm rim (ie gt50)
bull14-18 G cannula safe triangle (or 2ICS if contraindicated) - aspirate
bullDrain 8-14 FG is usually adequate although 28 FG may be required with
mechanical ventilation
Other considerations
bullNo improvement with drain ndash suction cardiothoracic involvement
httpthoraxbmjcomcontent58suppl_2ii39full
httpssecurecollemergencymedacukcodedocumentaspID=6194
Describe the treatment for
Pneumothorax
httpwwwbrit-thoracicorgukPortals0GuidelinesPleuralDiseaseGuidelinesPleural20Guideline202010Pleural20disease20201020pneumothoraxpdf
Emergency Department HMO education series
2012
Case B2
22 yo 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
Emergency Department HMO education series
2012
Further history amp 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
11070
Sat 97 RA
Widespread wheeze
(what causes this
sound)
Emergency Department HMO education series
2012
Investigations
If the CXR is normal (ish)hellip
Peak Flow 250min (how does this help us)
ABG on room air pH 75 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
Emergency Department HMO education series
2012
Investigations
If the CXR is normalhellip
Peak Flow 250min (how does this help us)
ABG on room air pH 75 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
Emergency Department HMO education series
2012
BBH Asthma protocol
Emergency Department HMO education series
2012
Investigations
If the CXR is normalhellip
Peak Flow 250min (how does this help us)
ABG on room air pH 75 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
Emergency Department HMO education series
2012
Investigations
If the CXR is normalhellip
Peak Flow 300min (how does this help us)
ABG on room air pH 75 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
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 httpwwwnationalasthmaorgauhealth-professionalstools-for-primary-careasthma-action-plansasthma-action-
plan-library
Asthma sticker
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 httpwwwnationalasthmaorgauhealth-professionalstools-for-primary-careasthma-action-plansasthma-action-plan-
library
Discharge checklist
Follow up referral letter to GP
Copy of letter with patient (optional)
Current asthma action plan
Triggers identified
Medications prescribed including
Relievers-short acting B agonists
Preventers-steroids
Symptom controllers-long acting B agonists (if prescribed)
Ensure medications will last until arranged review
Spacer or other delivery systems available and patient
understands use and care
Asthma handouts given (patient information fact sheet)
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 httpwwwnationalasthmaorgauhealth-professionalstools-for-primary-careasthma-action-plansasthma-action-
plan-library
Example action plan
Emergency Department HMO education series
2012
Case B3
22 yo man
Brought to the ED by his partner
Gradual onset of SOB
Now present for few hours
What else do you want to know
Emergency Department HMO education series
2012
Further history amp examination
No wheeze
Productive cough
No recent URTI
Childhood asthma (age
3-12) hay fever
No cardiac history
No risk factors for PE
RR 34 HR 110 SR BP
8965
Sat 87 RA
Dull R base with coarse
crackles
Emergency Department HMO education series
2012
Investigations
The CXR is hellip
ABG on room air
pH 730 CO2 55
O2 70 HCO3 18
What do the blood gases
show
How severe is the
problem
Emergency Department HMO education series
2012
What scoring tools for
pneumonia
SMARTCOP CURB-65 Sepsis guidelines
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
SMARTCOP
SMARTCOP
SMARTCOP
CURB 65
Various website and apps can assist you in
remembering them wwwmdcalccom
Emergency Department HMO education series
2012
Case B4 - Female in her 60rsquos
Sudden onset SOB (present now for 1 hour quite
severe) right sided pleuritic chest pain
Mild fever
Right total knee replacement 3 days ago
persistent leg swelling since yesterday
Non-smoker
No previous cardiorespiratory disease
Emergency Department HMO education series
2012
What is the differential
diagnosis
Emergency Department HMO education series
2012
What is the differential
diagnosis
Most likely
PE
Next likely
Pneumonia
Less likely
Pneumothorax
Arrhythmia
AMI
Emergency Department HMO education series
2012
On examination amp tests
Tachypnoea and some WOB
RR 24 T 376 HR 110 BP 11070
Sats 93 RA
Chest clear with normal percussion and normal breath
sounds
CXR normal
ABG pH 75 CO2 30mmHg p02 62mmHg on RA
Most likely diagnosis
What are Wells criteria
What are Wells criteria
PERC
D-Dimer
What test do you want to do
Emergency Department HMO education series
2012
What can you see
Emergency Department HMO education series
2012
Filling defect R main pulmonary trunk
Emergency Department HMO education series
2012
Emergency Department HMO education series
2012
Case C Man in 60rsquos
Woke this am very SOB and distressed ndash called
ambulance
Progressive SOB over 6 months
Chronic cough
Usually with white sputum
Now worse with no change in sputum colour
No associated fever
SOB in night ndash gets up
Ankles swollen recently
Heavy smoker (35 pack years)
Admission to local hospital 612 ago with chest pains
Emergency Department HMO education series
2012
Differential diagnosis
CCF with acute exacerbation
Chronic obstructive pulmonary disease
(COPD) with acute infective exacerbation
Anaemia
Emergency Department HMO education series
2012
Exam amp investigationshellip
Unwell RR 36 T 368 HR 90 SR BP 180102
Satrsquos 88 RA
Evidence of work of breathing and use of accessory muscles (which are these)
Pursed lip breathing
Prolonged expiration with wheeze
ABG pH 728 pCO2 60 pO2 55 HCO3 26
What do these show
Do you want a CXR
Emergency Department HMO education series
2012
Emergency Department HMO education series
2012
Diagnosis
Acute cardiac failure ndash APO
Most likely cause
Treatment
ECG ndash filed unsigned and
unseen
Emergency Department HMO education series
2012
Diagnosis
Acute cardiac failure ndash APO
Most likely cause
Treatment
Emergency Department HMO education series
2012
Diagnosis - APO
Acute cardiac failure
Treatment
Medications Nitroglycerin SL topical or IV titrated to avoid hypotension Most rapidly
venodilates reduces LV afterload and corrects myocardial ischaemia
Frusemide IV Despite universal use absolute efficacy is unclear
Ventilatory Assistance Non-invasive ventilation (NIV) reduces mortality by 40 particularly with CPAP
and reduces need to intubate
Emergency Department HMO education series
2012
Case C2 - Male in 60rsquos
Progressive SOB over 6 months worse over 24 hours
Orthopnoea Paroxysmal nocturnal dyspnoea (PND) SOA All present to a minor degree over the 6 months but worse for 24 hours
Palpitations (last 24 hours)
Previous AMI 4 years ago pace maker
Ex-smoker Hypertension (HT) diabetes
Emergency Department HMO education series
2012
Examination
Unwell looking with increased work of breathing
RR 26 afeb HR Irreg 130 BP 10070
Sat 90 RA
JVP 5cm
SOA ++
Displaced apex beat no cardiac murmurs 3rd heart sound present
Normal chest expansion but stony dull percussion in the bases (RgtL) bilateral inspiratory crepitations just above the dull areas
ECG ndash what is your diagnosis
Emergency Department HMO education series
2012
Cardiac failure
Emergency Department HMO education series
2012
Case C2 - Summary
Long standing heart failure with an acute
exacerbation due to new onset rapid AF
Treatment of AF amp heart failure
Antithrombotic strategy
Then rate control
Perhaps rhythm control
See review article re AF treatment
To be published early 2013 Australian Rural Doctor
Case D
Mid 60s male
Found SOB ++ in street
Ambulance called
In ED
SOB at rest
Doesnt want help
Funny smell
Further information
Dishevelled
HR 120 reg BP 9560 Sats 94 RA
Vomiting intermittently
What will you do
Further treatment and
investigation
Further history from patient and collateral
sources
Resuscitation
IV access fluids
Bloods ndash FBC UEC CMP Blood gas
pH 71 pCO2 20 pO2 90 HCO3 10 BE -16
Further treatment and
investigation
Further history from patient and collateral
sources
Resuscitation
IV access fluids
Bloods ndash FBC UEC CMP Blood gas
pH 71 pCO2 20 pO2 90 HCO3 10 BE -16
BSL gt30
Further treatment and
investigation
Treatment
IV fluids ndash caution with Na and cerebral oedema
IV insulin
001 ndash 01 unitskghr
aim for BSL 2mmolL drop per hour
Continue until metabolic correction
Monitor and correct K+ other electrolytes
Monitor urine ketones VBGABG
Identify precipitant
Resolution
Wife arrives and is relieved to find husband
Chairman of Rotary Club
UTI developed whilst wife away for weekend
Questions
Summary
Diagnosis of the breathless patient requires you to look for clueshellip The time course of the illness
Associated symptoms
Known diseases or risk factors for disease
Treatment of illnesses supported by evidence for pneumonia asthma PE AF etc
Interpretation of radiology best done with clinical context
Thankyou
Emergency Department HMO education series
2012
What else should I ask
Travel historyhellip
Other important symptoms of respiratory
disease
Cough
Acute
Chronic
Haemoptysis (cancer TB other infections)
Chest Pain
Daytime sleepiness (obstructive sleep apnea)
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
What is your differential
Croup
FB
Epiglottitis
Upper airway massswelling
Functional
Emergency Department HMO education series
2013
Emergency Department HMO education series
2012
What else might you elicit in
the history
What else might you elicit in
the history Recent or current viral illness in child sibs or
kinderchild care
Similar events in the past
Immunisation history (How many doses of Hib and when)
Fluids and food intake
How parentcarer feels about behavior
Possible FB
Emergency Department HMO education series
2013
On review
Child becomes distressed when you
approach and attempt to examine
Remember
Emergency Department HMO education series
2013
Emergency Department HMO education series
2012
On review
Child becomes distressed when you
approach and attempt to examine
Emergency Department HMO education series
2012
On review
Child becomes distressed when you
approach and attempt to examine
St Gurnasty Infirmary Unpleasantshire Hospitals
Services Trust
Kill or be killed
On review
Child becomes distressed when you
approach and attempt to examine
Intercostal recession marked
Tracheal tug noted
Also note respiratory rate O2 requirements
Emergency Department HMO education series
2013
text
Croup
Emergency Department HMO education series
2013
Treatment
Steroids have been shown to decrease the length of hospital stay need for nebulised Adrenaline and
other interventions
Mild to Moderate Croup
Prednisolone 1mgkg AND prescribe a second dose for the next evening OR a single dose of
Oral Dexamethasone 015mgkg Observe for half an hour post steroid administration Discharge
once stridor-free at rest
Severe croup
Nebulised adrenaline (1 mL of 1 adrenaline diluted to 4 ml with Normal Saline or 5ml of adrenaline
11000)
AND
Give 06mgkg (max 12mg) IMIV dexamethasone
Emergency Department HMO education series
2013
Case B
22 yo man
Brought to the ED by his partner
Sudden onset of SOB
Now present for few hours
How is your differential diagnosis affected by
the sudden onset
Emergency Department HMO education series
2013
Further history
Previously well smokes 10 cigarettesday
Left sided chest pain
Moderate
Pleuritic
Started with the SOB
Is there anything else you would like to ask
What is your differential diagnosis
Emergency Department HMO education series
2013
Emergency Department HMO education series
2012
Differential diagnosis
Pneumothorax
Arrhythmia
Pulmonary Embolism
Asthma (less likely)
Pneumonia
Anxiety
Emergency Department HMO education series
2012
Differential diagnosis
Pneumothorax
Arrhythmia
Pulmonary Embolism
Asthma (less likely)
Pneumonia
Anxiety (Imagine that being your diagnosis and you missed a pound$^ your honour)
You horrible
little doctor
Emergency Department HMO education series
2012
Examination findings
Looks unwell quite distressed with WOB
RR 26 HR 125 SR BP 8060 afebrile
Saturation 93 RA (room air)
Trachea midline
chest expansion on the left
Hyper-resonant percussion note on the left
air entry left lung
What is going on
Is this serious
What is your immediate management
Emergency Department HMO education series
2012
Describe this CXR
Emergency Department HMO education series
2012
Describe this CXR
gt or lt 2cm
Where gt 2cm then pneumothorax is gt50 and is considered large
Emergency Department HMO education series
2012
Describe this CXR
Bigger image next slide
Tethered
lung
gt2cm
Right shift of
mediastinum
Air next to
pericardium
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)
Tension
bullLarge bore cannula 2nd intercostal space mid-clavicular line
If large non-tension
bullgt2cm rim (ie gt50)
bull14-18 G cannula safe triangle (or 2ICS if contraindicated) - aspirate
bullDrain 8-14 FG is usually adequate although 28 FG may be required with
mechanical ventilation
Other considerations
bullNo improvement with drain ndash suction cardiothoracic involvement
httpthoraxbmjcomcontent58suppl_2ii39full
httpssecurecollemergencymedacukcodedocumentaspID=6194
Describe the treatment for
Pneumothorax
httpwwwbrit-thoracicorgukPortals0GuidelinesPleuralDiseaseGuidelinesPleural20Guideline202010Pleural20disease20201020pneumothoraxpdf
Emergency Department HMO education series
2012
Case B2
22 yo 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
Emergency Department HMO education series
2012
Further history amp 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
11070
Sat 97 RA
Widespread wheeze
(what causes this
sound)
Emergency Department HMO education series
2012
Investigations
If the CXR is normal (ish)hellip
Peak Flow 250min (how does this help us)
ABG on room air pH 75 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
Emergency Department HMO education series
2012
Investigations
If the CXR is normalhellip
Peak Flow 250min (how does this help us)
ABG on room air pH 75 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
Emergency Department HMO education series
2012
BBH Asthma protocol
Emergency Department HMO education series
2012
Investigations
If the CXR is normalhellip
Peak Flow 250min (how does this help us)
ABG on room air pH 75 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
Emergency Department HMO education series
2012
Investigations
If the CXR is normalhellip
Peak Flow 300min (how does this help us)
ABG on room air pH 75 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
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 httpwwwnationalasthmaorgauhealth-professionalstools-for-primary-careasthma-action-plansasthma-action-
plan-library
Asthma sticker
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 httpwwwnationalasthmaorgauhealth-professionalstools-for-primary-careasthma-action-plansasthma-action-plan-
library
Discharge checklist
Follow up referral letter to GP
Copy of letter with patient (optional)
Current asthma action plan
Triggers identified
Medications prescribed including
Relievers-short acting B agonists
Preventers-steroids
Symptom controllers-long acting B agonists (if prescribed)
Ensure medications will last until arranged review
Spacer or other delivery systems available and patient
understands use and care
Asthma handouts given (patient information fact sheet)
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 httpwwwnationalasthmaorgauhealth-professionalstools-for-primary-careasthma-action-plansasthma-action-
plan-library
Example action plan
Emergency Department HMO education series
2012
Case B3
22 yo man
Brought to the ED by his partner
Gradual onset of SOB
Now present for few hours
What else do you want to know
Emergency Department HMO education series
2012
Further history amp examination
No wheeze
Productive cough
No recent URTI
Childhood asthma (age
3-12) hay fever
No cardiac history
No risk factors for PE
RR 34 HR 110 SR BP
8965
Sat 87 RA
Dull R base with coarse
crackles
Emergency Department HMO education series
2012
Investigations
The CXR is hellip
ABG on room air
pH 730 CO2 55
O2 70 HCO3 18
What do the blood gases
show
How severe is the
problem
Emergency Department HMO education series
2012
What scoring tools for
pneumonia
SMARTCOP CURB-65 Sepsis guidelines
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
SMARTCOP
SMARTCOP
SMARTCOP
CURB 65
Various website and apps can assist you in
remembering them wwwmdcalccom
Emergency Department HMO education series
2012
Case B4 - Female in her 60rsquos
Sudden onset SOB (present now for 1 hour quite
severe) right sided pleuritic chest pain
Mild fever
Right total knee replacement 3 days ago
persistent leg swelling since yesterday
Non-smoker
No previous cardiorespiratory disease
Emergency Department HMO education series
2012
What is the differential
diagnosis
Emergency Department HMO education series
2012
What is the differential
diagnosis
Most likely
PE
Next likely
Pneumonia
Less likely
Pneumothorax
Arrhythmia
AMI
Emergency Department HMO education series
2012
On examination amp tests
Tachypnoea and some WOB
RR 24 T 376 HR 110 BP 11070
Sats 93 RA
Chest clear with normal percussion and normal breath
sounds
CXR normal
ABG pH 75 CO2 30mmHg p02 62mmHg on RA
Most likely diagnosis
What are Wells criteria
What are Wells criteria
PERC
D-Dimer
What test do you want to do
Emergency Department HMO education series
2012
What can you see
Emergency Department HMO education series
2012
Filling defect R main pulmonary trunk
Emergency Department HMO education series
2012
Emergency Department HMO education series
2012
Case C Man in 60rsquos
Woke this am very SOB and distressed ndash called
ambulance
Progressive SOB over 6 months
Chronic cough
Usually with white sputum
Now worse with no change in sputum colour
No associated fever
SOB in night ndash gets up
Ankles swollen recently
Heavy smoker (35 pack years)
Admission to local hospital 612 ago with chest pains
Emergency Department HMO education series
2012
Differential diagnosis
CCF with acute exacerbation
Chronic obstructive pulmonary disease
(COPD) with acute infective exacerbation
Anaemia
Emergency Department HMO education series
2012
Exam amp investigationshellip
Unwell RR 36 T 368 HR 90 SR BP 180102
Satrsquos 88 RA
Evidence of work of breathing and use of accessory muscles (which are these)
Pursed lip breathing
Prolonged expiration with wheeze
ABG pH 728 pCO2 60 pO2 55 HCO3 26
What do these show
Do you want a CXR
Emergency Department HMO education series
2012
Emergency Department HMO education series
2012
Diagnosis
Acute cardiac failure ndash APO
Most likely cause
Treatment
ECG ndash filed unsigned and
unseen
Emergency Department HMO education series
2012
Diagnosis
Acute cardiac failure ndash APO
Most likely cause
Treatment
Emergency Department HMO education series
2012
Diagnosis - APO
Acute cardiac failure
Treatment
Medications Nitroglycerin SL topical or IV titrated to avoid hypotension Most rapidly
venodilates reduces LV afterload and corrects myocardial ischaemia
Frusemide IV Despite universal use absolute efficacy is unclear
Ventilatory Assistance Non-invasive ventilation (NIV) reduces mortality by 40 particularly with CPAP
and reduces need to intubate
Emergency Department HMO education series
2012
Case C2 - Male in 60rsquos
Progressive SOB over 6 months worse over 24 hours
Orthopnoea Paroxysmal nocturnal dyspnoea (PND) SOA All present to a minor degree over the 6 months but worse for 24 hours
Palpitations (last 24 hours)
Previous AMI 4 years ago pace maker
Ex-smoker Hypertension (HT) diabetes
Emergency Department HMO education series
2012
Examination
Unwell looking with increased work of breathing
RR 26 afeb HR Irreg 130 BP 10070
Sat 90 RA
JVP 5cm
SOA ++
Displaced apex beat no cardiac murmurs 3rd heart sound present
Normal chest expansion but stony dull percussion in the bases (RgtL) bilateral inspiratory crepitations just above the dull areas
ECG ndash what is your diagnosis
Emergency Department HMO education series
2012
Cardiac failure
Emergency Department HMO education series
2012
Case C2 - Summary
Long standing heart failure with an acute
exacerbation due to new onset rapid AF
Treatment of AF amp heart failure
Antithrombotic strategy
Then rate control
Perhaps rhythm control
See review article re AF treatment
To be published early 2013 Australian Rural Doctor
Case D
Mid 60s male
Found SOB ++ in street
Ambulance called
In ED
SOB at rest
Doesnt want help
Funny smell
Further information
Dishevelled
HR 120 reg BP 9560 Sats 94 RA
Vomiting intermittently
What will you do
Further treatment and
investigation
Further history from patient and collateral
sources
Resuscitation
IV access fluids
Bloods ndash FBC UEC CMP Blood gas
pH 71 pCO2 20 pO2 90 HCO3 10 BE -16
Further treatment and
investigation
Further history from patient and collateral
sources
Resuscitation
IV access fluids
Bloods ndash FBC UEC CMP Blood gas
pH 71 pCO2 20 pO2 90 HCO3 10 BE -16
BSL gt30
Further treatment and
investigation
Treatment
IV fluids ndash caution with Na and cerebral oedema
IV insulin
001 ndash 01 unitskghr
aim for BSL 2mmolL drop per hour
Continue until metabolic correction
Monitor and correct K+ other electrolytes
Monitor urine ketones VBGABG
Identify precipitant
Resolution
Wife arrives and is relieved to find husband
Chairman of Rotary Club
UTI developed whilst wife away for weekend
Questions
Summary
Diagnosis of the breathless patient requires you to look for clueshellip The time course of the illness
Associated symptoms
Known diseases or risk factors for disease
Treatment of illnesses supported by evidence for pneumonia asthma PE AF etc
Interpretation of radiology best done with clinical context
Thankyou
Emergency Department HMO education series
2012
What else should I ask
Travel historyhellip
Other important symptoms of respiratory
disease
Cough
Acute
Chronic
Haemoptysis (cancer TB other infections)
Chest Pain
Daytime sleepiness (obstructive sleep apnea)
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Emergency Department HMO education series
2012
What else might you elicit in
the history
What else might you elicit in
the history Recent or current viral illness in child sibs or
kinderchild care
Similar events in the past
Immunisation history (How many doses of Hib and when)
Fluids and food intake
How parentcarer feels about behavior
Possible FB
Emergency Department HMO education series
2013
On review
Child becomes distressed when you
approach and attempt to examine
Remember
Emergency Department HMO education series
2013
Emergency Department HMO education series
2012
On review
Child becomes distressed when you
approach and attempt to examine
Emergency Department HMO education series
2012
On review
Child becomes distressed when you
approach and attempt to examine
St Gurnasty Infirmary Unpleasantshire Hospitals
Services Trust
Kill or be killed
On review
Child becomes distressed when you
approach and attempt to examine
Intercostal recession marked
Tracheal tug noted
Also note respiratory rate O2 requirements
Emergency Department HMO education series
2013
text
Croup
Emergency Department HMO education series
2013
Treatment
Steroids have been shown to decrease the length of hospital stay need for nebulised Adrenaline and
other interventions
Mild to Moderate Croup
Prednisolone 1mgkg AND prescribe a second dose for the next evening OR a single dose of
Oral Dexamethasone 015mgkg Observe for half an hour post steroid administration Discharge
once stridor-free at rest
Severe croup
Nebulised adrenaline (1 mL of 1 adrenaline diluted to 4 ml with Normal Saline or 5ml of adrenaline
11000)
AND
Give 06mgkg (max 12mg) IMIV dexamethasone
Emergency Department HMO education series
2013
Case B
22 yo man
Brought to the ED by his partner
Sudden onset of SOB
Now present for few hours
How is your differential diagnosis affected by
the sudden onset
Emergency Department HMO education series
2013
Further history
Previously well smokes 10 cigarettesday
Left sided chest pain
Moderate
Pleuritic
Started with the SOB
Is there anything else you would like to ask
What is your differential diagnosis
Emergency Department HMO education series
2013
Emergency Department HMO education series
2012
Differential diagnosis
Pneumothorax
Arrhythmia
Pulmonary Embolism
Asthma (less likely)
Pneumonia
Anxiety
Emergency Department HMO education series
2012
Differential diagnosis
Pneumothorax
Arrhythmia
Pulmonary Embolism
Asthma (less likely)
Pneumonia
Anxiety (Imagine that being your diagnosis and you missed a pound$^ your honour)
You horrible
little doctor
Emergency Department HMO education series
2012
Examination findings
Looks unwell quite distressed with WOB
RR 26 HR 125 SR BP 8060 afebrile
Saturation 93 RA (room air)
Trachea midline
chest expansion on the left
Hyper-resonant percussion note on the left
air entry left lung
What is going on
Is this serious
What is your immediate management
Emergency Department HMO education series
2012
Describe this CXR
Emergency Department HMO education series
2012
Describe this CXR
gt or lt 2cm
Where gt 2cm then pneumothorax is gt50 and is considered large
Emergency Department HMO education series
2012
Describe this CXR
Bigger image next slide
Tethered
lung
gt2cm
Right shift of
mediastinum
Air next to
pericardium
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)
Tension
bullLarge bore cannula 2nd intercostal space mid-clavicular line
If large non-tension
bullgt2cm rim (ie gt50)
bull14-18 G cannula safe triangle (or 2ICS if contraindicated) - aspirate
bullDrain 8-14 FG is usually adequate although 28 FG may be required with
mechanical ventilation
Other considerations
bullNo improvement with drain ndash suction cardiothoracic involvement
httpthoraxbmjcomcontent58suppl_2ii39full
httpssecurecollemergencymedacukcodedocumentaspID=6194
Describe the treatment for
Pneumothorax
httpwwwbrit-thoracicorgukPortals0GuidelinesPleuralDiseaseGuidelinesPleural20Guideline202010Pleural20disease20201020pneumothoraxpdf
Emergency Department HMO education series
2012
Case B2
22 yo 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
Emergency Department HMO education series
2012
Further history amp 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
11070
Sat 97 RA
Widespread wheeze
(what causes this
sound)
Emergency Department HMO education series
2012
Investigations
If the CXR is normal (ish)hellip
Peak Flow 250min (how does this help us)
ABG on room air pH 75 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
Emergency Department HMO education series
2012
Investigations
If the CXR is normalhellip
Peak Flow 250min (how does this help us)
ABG on room air pH 75 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
Emergency Department HMO education series
2012
BBH Asthma protocol
Emergency Department HMO education series
2012
Investigations
If the CXR is normalhellip
Peak Flow 250min (how does this help us)
ABG on room air pH 75 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
Emergency Department HMO education series
2012
Investigations
If the CXR is normalhellip
Peak Flow 300min (how does this help us)
ABG on room air pH 75 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
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 httpwwwnationalasthmaorgauhealth-professionalstools-for-primary-careasthma-action-plansasthma-action-
plan-library
Asthma sticker
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 httpwwwnationalasthmaorgauhealth-professionalstools-for-primary-careasthma-action-plansasthma-action-plan-
library
Discharge checklist
Follow up referral letter to GP
Copy of letter with patient (optional)
Current asthma action plan
Triggers identified
Medications prescribed including
Relievers-short acting B agonists
Preventers-steroids
Symptom controllers-long acting B agonists (if prescribed)
Ensure medications will last until arranged review
Spacer or other delivery systems available and patient
understands use and care
Asthma handouts given (patient information fact sheet)
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 httpwwwnationalasthmaorgauhealth-professionalstools-for-primary-careasthma-action-plansasthma-action-
plan-library
Example action plan
Emergency Department HMO education series
2012
Case B3
22 yo man
Brought to the ED by his partner
Gradual onset of SOB
Now present for few hours
What else do you want to know
Emergency Department HMO education series
2012
Further history amp examination
No wheeze
Productive cough
No recent URTI
Childhood asthma (age
3-12) hay fever
No cardiac history
No risk factors for PE
RR 34 HR 110 SR BP
8965
Sat 87 RA
Dull R base with coarse
crackles
Emergency Department HMO education series
2012
Investigations
The CXR is hellip
ABG on room air
pH 730 CO2 55
O2 70 HCO3 18
What do the blood gases
show
How severe is the
problem
Emergency Department HMO education series
2012
What scoring tools for
pneumonia
SMARTCOP CURB-65 Sepsis guidelines
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
SMARTCOP
SMARTCOP
SMARTCOP
CURB 65
Various website and apps can assist you in
remembering them wwwmdcalccom
Emergency Department HMO education series
2012
Case B4 - Female in her 60rsquos
Sudden onset SOB (present now for 1 hour quite
severe) right sided pleuritic chest pain
Mild fever
Right total knee replacement 3 days ago
persistent leg swelling since yesterday
Non-smoker
No previous cardiorespiratory disease
Emergency Department HMO education series
2012
What is the differential
diagnosis
Emergency Department HMO education series
2012
What is the differential
diagnosis
Most likely
PE
Next likely
Pneumonia
Less likely
Pneumothorax
Arrhythmia
AMI
Emergency Department HMO education series
2012
On examination amp tests
Tachypnoea and some WOB
RR 24 T 376 HR 110 BP 11070
Sats 93 RA
Chest clear with normal percussion and normal breath
sounds
CXR normal
ABG pH 75 CO2 30mmHg p02 62mmHg on RA
Most likely diagnosis
What are Wells criteria
What are Wells criteria
PERC
D-Dimer
What test do you want to do
Emergency Department HMO education series
2012
What can you see
Emergency Department HMO education series
2012
Filling defect R main pulmonary trunk
Emergency Department HMO education series
2012
Emergency Department HMO education series
2012
Case C Man in 60rsquos
Woke this am very SOB and distressed ndash called
ambulance
Progressive SOB over 6 months
Chronic cough
Usually with white sputum
Now worse with no change in sputum colour
No associated fever
SOB in night ndash gets up
Ankles swollen recently
Heavy smoker (35 pack years)
Admission to local hospital 612 ago with chest pains
Emergency Department HMO education series
2012
Differential diagnosis
CCF with acute exacerbation
Chronic obstructive pulmonary disease
(COPD) with acute infective exacerbation
Anaemia
Emergency Department HMO education series
2012
Exam amp investigationshellip
Unwell RR 36 T 368 HR 90 SR BP 180102
Satrsquos 88 RA
Evidence of work of breathing and use of accessory muscles (which are these)
Pursed lip breathing
Prolonged expiration with wheeze
ABG pH 728 pCO2 60 pO2 55 HCO3 26
What do these show
Do you want a CXR
Emergency Department HMO education series
2012
Emergency Department HMO education series
2012
Diagnosis
Acute cardiac failure ndash APO
Most likely cause
Treatment
ECG ndash filed unsigned and
unseen
Emergency Department HMO education series
2012
Diagnosis
Acute cardiac failure ndash APO
Most likely cause
Treatment
Emergency Department HMO education series
2012
Diagnosis - APO
Acute cardiac failure
Treatment
Medications Nitroglycerin SL topical or IV titrated to avoid hypotension Most rapidly
venodilates reduces LV afterload and corrects myocardial ischaemia
Frusemide IV Despite universal use absolute efficacy is unclear
Ventilatory Assistance Non-invasive ventilation (NIV) reduces mortality by 40 particularly with CPAP
and reduces need to intubate
Emergency Department HMO education series
2012
Case C2 - Male in 60rsquos
Progressive SOB over 6 months worse over 24 hours
Orthopnoea Paroxysmal nocturnal dyspnoea (PND) SOA All present to a minor degree over the 6 months but worse for 24 hours
Palpitations (last 24 hours)
Previous AMI 4 years ago pace maker
Ex-smoker Hypertension (HT) diabetes
Emergency Department HMO education series
2012
Examination
Unwell looking with increased work of breathing
RR 26 afeb HR Irreg 130 BP 10070
Sat 90 RA
JVP 5cm
SOA ++
Displaced apex beat no cardiac murmurs 3rd heart sound present
Normal chest expansion but stony dull percussion in the bases (RgtL) bilateral inspiratory crepitations just above the dull areas
ECG ndash what is your diagnosis
Emergency Department HMO education series
2012
Cardiac failure
Emergency Department HMO education series
2012
Case C2 - Summary
Long standing heart failure with an acute
exacerbation due to new onset rapid AF
Treatment of AF amp heart failure
Antithrombotic strategy
Then rate control
Perhaps rhythm control
See review article re AF treatment
To be published early 2013 Australian Rural Doctor
Case D
Mid 60s male
Found SOB ++ in street
Ambulance called
In ED
SOB at rest
Doesnt want help
Funny smell
Further information
Dishevelled
HR 120 reg BP 9560 Sats 94 RA
Vomiting intermittently
What will you do
Further treatment and
investigation
Further history from patient and collateral
sources
Resuscitation
IV access fluids
Bloods ndash FBC UEC CMP Blood gas
pH 71 pCO2 20 pO2 90 HCO3 10 BE -16
Further treatment and
investigation
Further history from patient and collateral
sources
Resuscitation
IV access fluids
Bloods ndash FBC UEC CMP Blood gas
pH 71 pCO2 20 pO2 90 HCO3 10 BE -16
BSL gt30
Further treatment and
investigation
Treatment
IV fluids ndash caution with Na and cerebral oedema
IV insulin
001 ndash 01 unitskghr
aim for BSL 2mmolL drop per hour
Continue until metabolic correction
Monitor and correct K+ other electrolytes
Monitor urine ketones VBGABG
Identify precipitant
Resolution
Wife arrives and is relieved to find husband
Chairman of Rotary Club
UTI developed whilst wife away for weekend
Questions
Summary
Diagnosis of the breathless patient requires you to look for clueshellip The time course of the illness
Associated symptoms
Known diseases or risk factors for disease
Treatment of illnesses supported by evidence for pneumonia asthma PE AF etc
Interpretation of radiology best done with clinical context
Thankyou
Emergency Department HMO education series
2012
What else should I ask
Travel historyhellip
Other important symptoms of respiratory
disease
Cough
Acute
Chronic
Haemoptysis (cancer TB other infections)
Chest Pain
Daytime sleepiness (obstructive sleep apnea)
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
What else might you elicit in
the history Recent or current viral illness in child sibs or
kinderchild care
Similar events in the past
Immunisation history (How many doses of Hib and when)
Fluids and food intake
How parentcarer feels about behavior
Possible FB
Emergency Department HMO education series
2013
On review
Child becomes distressed when you
approach and attempt to examine
Remember
Emergency Department HMO education series
2013
Emergency Department HMO education series
2012
On review
Child becomes distressed when you
approach and attempt to examine
Emergency Department HMO education series
2012
On review
Child becomes distressed when you
approach and attempt to examine
St Gurnasty Infirmary Unpleasantshire Hospitals
Services Trust
Kill or be killed
On review
Child becomes distressed when you
approach and attempt to examine
Intercostal recession marked
Tracheal tug noted
Also note respiratory rate O2 requirements
Emergency Department HMO education series
2013
text
Croup
Emergency Department HMO education series
2013
Treatment
Steroids have been shown to decrease the length of hospital stay need for nebulised Adrenaline and
other interventions
Mild to Moderate Croup
Prednisolone 1mgkg AND prescribe a second dose for the next evening OR a single dose of
Oral Dexamethasone 015mgkg Observe for half an hour post steroid administration Discharge
once stridor-free at rest
Severe croup
Nebulised adrenaline (1 mL of 1 adrenaline diluted to 4 ml with Normal Saline or 5ml of adrenaline
11000)
AND
Give 06mgkg (max 12mg) IMIV dexamethasone
Emergency Department HMO education series
2013
Case B
22 yo man
Brought to the ED by his partner
Sudden onset of SOB
Now present for few hours
How is your differential diagnosis affected by
the sudden onset
Emergency Department HMO education series
2013
Further history
Previously well smokes 10 cigarettesday
Left sided chest pain
Moderate
Pleuritic
Started with the SOB
Is there anything else you would like to ask
What is your differential diagnosis
Emergency Department HMO education series
2013
Emergency Department HMO education series
2012
Differential diagnosis
Pneumothorax
Arrhythmia
Pulmonary Embolism
Asthma (less likely)
Pneumonia
Anxiety
Emergency Department HMO education series
2012
Differential diagnosis
Pneumothorax
Arrhythmia
Pulmonary Embolism
Asthma (less likely)
Pneumonia
Anxiety (Imagine that being your diagnosis and you missed a pound$^ your honour)
You horrible
little doctor
Emergency Department HMO education series
2012
Examination findings
Looks unwell quite distressed with WOB
RR 26 HR 125 SR BP 8060 afebrile
Saturation 93 RA (room air)
Trachea midline
chest expansion on the left
Hyper-resonant percussion note on the left
air entry left lung
What is going on
Is this serious
What is your immediate management
Emergency Department HMO education series
2012
Describe this CXR
Emergency Department HMO education series
2012
Describe this CXR
gt or lt 2cm
Where gt 2cm then pneumothorax is gt50 and is considered large
Emergency Department HMO education series
2012
Describe this CXR
Bigger image next slide
Tethered
lung
gt2cm
Right shift of
mediastinum
Air next to
pericardium
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)
Tension
bullLarge bore cannula 2nd intercostal space mid-clavicular line
If large non-tension
bullgt2cm rim (ie gt50)
bull14-18 G cannula safe triangle (or 2ICS if contraindicated) - aspirate
bullDrain 8-14 FG is usually adequate although 28 FG may be required with
mechanical ventilation
Other considerations
bullNo improvement with drain ndash suction cardiothoracic involvement
httpthoraxbmjcomcontent58suppl_2ii39full
httpssecurecollemergencymedacukcodedocumentaspID=6194
Describe the treatment for
Pneumothorax
httpwwwbrit-thoracicorgukPortals0GuidelinesPleuralDiseaseGuidelinesPleural20Guideline202010Pleural20disease20201020pneumothoraxpdf
Emergency Department HMO education series
2012
Case B2
22 yo 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
Emergency Department HMO education series
2012
Further history amp 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
11070
Sat 97 RA
Widespread wheeze
(what causes this
sound)
Emergency Department HMO education series
2012
Investigations
If the CXR is normal (ish)hellip
Peak Flow 250min (how does this help us)
ABG on room air pH 75 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
Emergency Department HMO education series
2012
Investigations
If the CXR is normalhellip
Peak Flow 250min (how does this help us)
ABG on room air pH 75 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
Emergency Department HMO education series
2012
BBH Asthma protocol
Emergency Department HMO education series
2012
Investigations
If the CXR is normalhellip
Peak Flow 250min (how does this help us)
ABG on room air pH 75 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
Emergency Department HMO education series
2012
Investigations
If the CXR is normalhellip
Peak Flow 300min (how does this help us)
ABG on room air pH 75 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
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 httpwwwnationalasthmaorgauhealth-professionalstools-for-primary-careasthma-action-plansasthma-action-
plan-library
Asthma sticker
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 httpwwwnationalasthmaorgauhealth-professionalstools-for-primary-careasthma-action-plansasthma-action-plan-
library
Discharge checklist
Follow up referral letter to GP
Copy of letter with patient (optional)
Current asthma action plan
Triggers identified
Medications prescribed including
Relievers-short acting B agonists
Preventers-steroids
Symptom controllers-long acting B agonists (if prescribed)
Ensure medications will last until arranged review
Spacer or other delivery systems available and patient
understands use and care
Asthma handouts given (patient information fact sheet)
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 httpwwwnationalasthmaorgauhealth-professionalstools-for-primary-careasthma-action-plansasthma-action-
plan-library
Example action plan
Emergency Department HMO education series
2012
Case B3
22 yo man
Brought to the ED by his partner
Gradual onset of SOB
Now present for few hours
What else do you want to know
Emergency Department HMO education series
2012
Further history amp examination
No wheeze
Productive cough
No recent URTI
Childhood asthma (age
3-12) hay fever
No cardiac history
No risk factors for PE
RR 34 HR 110 SR BP
8965
Sat 87 RA
Dull R base with coarse
crackles
Emergency Department HMO education series
2012
Investigations
The CXR is hellip
ABG on room air
pH 730 CO2 55
O2 70 HCO3 18
What do the blood gases
show
How severe is the
problem
Emergency Department HMO education series
2012
What scoring tools for
pneumonia
SMARTCOP CURB-65 Sepsis guidelines
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
SMARTCOP
SMARTCOP
SMARTCOP
CURB 65
Various website and apps can assist you in
remembering them wwwmdcalccom
Emergency Department HMO education series
2012
Case B4 - Female in her 60rsquos
Sudden onset SOB (present now for 1 hour quite
severe) right sided pleuritic chest pain
Mild fever
Right total knee replacement 3 days ago
persistent leg swelling since yesterday
Non-smoker
No previous cardiorespiratory disease
Emergency Department HMO education series
2012
What is the differential
diagnosis
Emergency Department HMO education series
2012
What is the differential
diagnosis
Most likely
PE
Next likely
Pneumonia
Less likely
Pneumothorax
Arrhythmia
AMI
Emergency Department HMO education series
2012
On examination amp tests
Tachypnoea and some WOB
RR 24 T 376 HR 110 BP 11070
Sats 93 RA
Chest clear with normal percussion and normal breath
sounds
CXR normal
ABG pH 75 CO2 30mmHg p02 62mmHg on RA
Most likely diagnosis
What are Wells criteria
What are Wells criteria
PERC
D-Dimer
What test do you want to do
Emergency Department HMO education series
2012
What can you see
Emergency Department HMO education series
2012
Filling defect R main pulmonary trunk
Emergency Department HMO education series
2012
Emergency Department HMO education series
2012
Case C Man in 60rsquos
Woke this am very SOB and distressed ndash called
ambulance
Progressive SOB over 6 months
Chronic cough
Usually with white sputum
Now worse with no change in sputum colour
No associated fever
SOB in night ndash gets up
Ankles swollen recently
Heavy smoker (35 pack years)
Admission to local hospital 612 ago with chest pains
Emergency Department HMO education series
2012
Differential diagnosis
CCF with acute exacerbation
Chronic obstructive pulmonary disease
(COPD) with acute infective exacerbation
Anaemia
Emergency Department HMO education series
2012
Exam amp investigationshellip
Unwell RR 36 T 368 HR 90 SR BP 180102
Satrsquos 88 RA
Evidence of work of breathing and use of accessory muscles (which are these)
Pursed lip breathing
Prolonged expiration with wheeze
ABG pH 728 pCO2 60 pO2 55 HCO3 26
What do these show
Do you want a CXR
Emergency Department HMO education series
2012
Emergency Department HMO education series
2012
Diagnosis
Acute cardiac failure ndash APO
Most likely cause
Treatment
ECG ndash filed unsigned and
unseen
Emergency Department HMO education series
2012
Diagnosis
Acute cardiac failure ndash APO
Most likely cause
Treatment
Emergency Department HMO education series
2012
Diagnosis - APO
Acute cardiac failure
Treatment
Medications Nitroglycerin SL topical or IV titrated to avoid hypotension Most rapidly
venodilates reduces LV afterload and corrects myocardial ischaemia
Frusemide IV Despite universal use absolute efficacy is unclear
Ventilatory Assistance Non-invasive ventilation (NIV) reduces mortality by 40 particularly with CPAP
and reduces need to intubate
Emergency Department HMO education series
2012
Case C2 - Male in 60rsquos
Progressive SOB over 6 months worse over 24 hours
Orthopnoea Paroxysmal nocturnal dyspnoea (PND) SOA All present to a minor degree over the 6 months but worse for 24 hours
Palpitations (last 24 hours)
Previous AMI 4 years ago pace maker
Ex-smoker Hypertension (HT) diabetes
Emergency Department HMO education series
2012
Examination
Unwell looking with increased work of breathing
RR 26 afeb HR Irreg 130 BP 10070
Sat 90 RA
JVP 5cm
SOA ++
Displaced apex beat no cardiac murmurs 3rd heart sound present
Normal chest expansion but stony dull percussion in the bases (RgtL) bilateral inspiratory crepitations just above the dull areas
ECG ndash what is your diagnosis
Emergency Department HMO education series
2012
Cardiac failure
Emergency Department HMO education series
2012
Case C2 - Summary
Long standing heart failure with an acute
exacerbation due to new onset rapid AF
Treatment of AF amp heart failure
Antithrombotic strategy
Then rate control
Perhaps rhythm control
See review article re AF treatment
To be published early 2013 Australian Rural Doctor
Case D
Mid 60s male
Found SOB ++ in street
Ambulance called
In ED
SOB at rest
Doesnt want help
Funny smell
Further information
Dishevelled
HR 120 reg BP 9560 Sats 94 RA
Vomiting intermittently
What will you do
Further treatment and
investigation
Further history from patient and collateral
sources
Resuscitation
IV access fluids
Bloods ndash FBC UEC CMP Blood gas
pH 71 pCO2 20 pO2 90 HCO3 10 BE -16
Further treatment and
investigation
Further history from patient and collateral
sources
Resuscitation
IV access fluids
Bloods ndash FBC UEC CMP Blood gas
pH 71 pCO2 20 pO2 90 HCO3 10 BE -16
BSL gt30
Further treatment and
investigation
Treatment
IV fluids ndash caution with Na and cerebral oedema
IV insulin
001 ndash 01 unitskghr
aim for BSL 2mmolL drop per hour
Continue until metabolic correction
Monitor and correct K+ other electrolytes
Monitor urine ketones VBGABG
Identify precipitant
Resolution
Wife arrives and is relieved to find husband
Chairman of Rotary Club
UTI developed whilst wife away for weekend
Questions
Summary
Diagnosis of the breathless patient requires you to look for clueshellip The time course of the illness
Associated symptoms
Known diseases or risk factors for disease
Treatment of illnesses supported by evidence for pneumonia asthma PE AF etc
Interpretation of radiology best done with clinical context
Thankyou
Emergency Department HMO education series
2012
What else should I ask
Travel historyhellip
Other important symptoms of respiratory
disease
Cough
Acute
Chronic
Haemoptysis (cancer TB other infections)
Chest Pain
Daytime sleepiness (obstructive sleep apnea)
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
On review
Child becomes distressed when you
approach and attempt to examine
Remember
Emergency Department HMO education series
2013
Emergency Department HMO education series
2012
On review
Child becomes distressed when you
approach and attempt to examine
Emergency Department HMO education series
2012
On review
Child becomes distressed when you
approach and attempt to examine
St Gurnasty Infirmary Unpleasantshire Hospitals
Services Trust
Kill or be killed
On review
Child becomes distressed when you
approach and attempt to examine
Intercostal recession marked
Tracheal tug noted
Also note respiratory rate O2 requirements
Emergency Department HMO education series
2013
text
Croup
Emergency Department HMO education series
2013
Treatment
Steroids have been shown to decrease the length of hospital stay need for nebulised Adrenaline and
other interventions
Mild to Moderate Croup
Prednisolone 1mgkg AND prescribe a second dose for the next evening OR a single dose of
Oral Dexamethasone 015mgkg Observe for half an hour post steroid administration Discharge
once stridor-free at rest
Severe croup
Nebulised adrenaline (1 mL of 1 adrenaline diluted to 4 ml with Normal Saline or 5ml of adrenaline
11000)
AND
Give 06mgkg (max 12mg) IMIV dexamethasone
Emergency Department HMO education series
2013
Case B
22 yo man
Brought to the ED by his partner
Sudden onset of SOB
Now present for few hours
How is your differential diagnosis affected by
the sudden onset
Emergency Department HMO education series
2013
Further history
Previously well smokes 10 cigarettesday
Left sided chest pain
Moderate
Pleuritic
Started with the SOB
Is there anything else you would like to ask
What is your differential diagnosis
Emergency Department HMO education series
2013
Emergency Department HMO education series
2012
Differential diagnosis
Pneumothorax
Arrhythmia
Pulmonary Embolism
Asthma (less likely)
Pneumonia
Anxiety
Emergency Department HMO education series
2012
Differential diagnosis
Pneumothorax
Arrhythmia
Pulmonary Embolism
Asthma (less likely)
Pneumonia
Anxiety (Imagine that being your diagnosis and you missed a pound$^ your honour)
You horrible
little doctor
Emergency Department HMO education series
2012
Examination findings
Looks unwell quite distressed with WOB
RR 26 HR 125 SR BP 8060 afebrile
Saturation 93 RA (room air)
Trachea midline
chest expansion on the left
Hyper-resonant percussion note on the left
air entry left lung
What is going on
Is this serious
What is your immediate management
Emergency Department HMO education series
2012
Describe this CXR
Emergency Department HMO education series
2012
Describe this CXR
gt or lt 2cm
Where gt 2cm then pneumothorax is gt50 and is considered large
Emergency Department HMO education series
2012
Describe this CXR
Bigger image next slide
Tethered
lung
gt2cm
Right shift of
mediastinum
Air next to
pericardium
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)
Tension
bullLarge bore cannula 2nd intercostal space mid-clavicular line
If large non-tension
bullgt2cm rim (ie gt50)
bull14-18 G cannula safe triangle (or 2ICS if contraindicated) - aspirate
bullDrain 8-14 FG is usually adequate although 28 FG may be required with
mechanical ventilation
Other considerations
bullNo improvement with drain ndash suction cardiothoracic involvement
httpthoraxbmjcomcontent58suppl_2ii39full
httpssecurecollemergencymedacukcodedocumentaspID=6194
Describe the treatment for
Pneumothorax
httpwwwbrit-thoracicorgukPortals0GuidelinesPleuralDiseaseGuidelinesPleural20Guideline202010Pleural20disease20201020pneumothoraxpdf
Emergency Department HMO education series
2012
Case B2
22 yo 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
Emergency Department HMO education series
2012
Further history amp 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
11070
Sat 97 RA
Widespread wheeze
(what causes this
sound)
Emergency Department HMO education series
2012
Investigations
If the CXR is normal (ish)hellip
Peak Flow 250min (how does this help us)
ABG on room air pH 75 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
Emergency Department HMO education series
2012
Investigations
If the CXR is normalhellip
Peak Flow 250min (how does this help us)
ABG on room air pH 75 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
Emergency Department HMO education series
2012
BBH Asthma protocol
Emergency Department HMO education series
2012
Investigations
If the CXR is normalhellip
Peak Flow 250min (how does this help us)
ABG on room air pH 75 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
Emergency Department HMO education series
2012
Investigations
If the CXR is normalhellip
Peak Flow 300min (how does this help us)
ABG on room air pH 75 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
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 httpwwwnationalasthmaorgauhealth-professionalstools-for-primary-careasthma-action-plansasthma-action-
plan-library
Asthma sticker
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 httpwwwnationalasthmaorgauhealth-professionalstools-for-primary-careasthma-action-plansasthma-action-plan-
library
Discharge checklist
Follow up referral letter to GP
Copy of letter with patient (optional)
Current asthma action plan
Triggers identified
Medications prescribed including
Relievers-short acting B agonists
Preventers-steroids
Symptom controllers-long acting B agonists (if prescribed)
Ensure medications will last until arranged review
Spacer or other delivery systems available and patient
understands use and care
Asthma handouts given (patient information fact sheet)
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 httpwwwnationalasthmaorgauhealth-professionalstools-for-primary-careasthma-action-plansasthma-action-
plan-library
Example action plan
Emergency Department HMO education series
2012
Case B3
22 yo man
Brought to the ED by his partner
Gradual onset of SOB
Now present for few hours
What else do you want to know
Emergency Department HMO education series
2012
Further history amp examination
No wheeze
Productive cough
No recent URTI
Childhood asthma (age
3-12) hay fever
No cardiac history
No risk factors for PE
RR 34 HR 110 SR BP
8965
Sat 87 RA
Dull R base with coarse
crackles
Emergency Department HMO education series
2012
Investigations
The CXR is hellip
ABG on room air
pH 730 CO2 55
O2 70 HCO3 18
What do the blood gases
show
How severe is the
problem
Emergency Department HMO education series
2012
What scoring tools for
pneumonia
SMARTCOP CURB-65 Sepsis guidelines
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
SMARTCOP
SMARTCOP
SMARTCOP
CURB 65
Various website and apps can assist you in
remembering them wwwmdcalccom
Emergency Department HMO education series
2012
Case B4 - Female in her 60rsquos
Sudden onset SOB (present now for 1 hour quite
severe) right sided pleuritic chest pain
Mild fever
Right total knee replacement 3 days ago
persistent leg swelling since yesterday
Non-smoker
No previous cardiorespiratory disease
Emergency Department HMO education series
2012
What is the differential
diagnosis
Emergency Department HMO education series
2012
What is the differential
diagnosis
Most likely
PE
Next likely
Pneumonia
Less likely
Pneumothorax
Arrhythmia
AMI
Emergency Department HMO education series
2012
On examination amp tests
Tachypnoea and some WOB
RR 24 T 376 HR 110 BP 11070
Sats 93 RA
Chest clear with normal percussion and normal breath
sounds
CXR normal
ABG pH 75 CO2 30mmHg p02 62mmHg on RA
Most likely diagnosis
What are Wells criteria
What are Wells criteria
PERC
D-Dimer
What test do you want to do
Emergency Department HMO education series
2012
What can you see
Emergency Department HMO education series
2012
Filling defect R main pulmonary trunk
Emergency Department HMO education series
2012
Emergency Department HMO education series
2012
Case C Man in 60rsquos
Woke this am very SOB and distressed ndash called
ambulance
Progressive SOB over 6 months
Chronic cough
Usually with white sputum
Now worse with no change in sputum colour
No associated fever
SOB in night ndash gets up
Ankles swollen recently
Heavy smoker (35 pack years)
Admission to local hospital 612 ago with chest pains
Emergency Department HMO education series
2012
Differential diagnosis
CCF with acute exacerbation
Chronic obstructive pulmonary disease
(COPD) with acute infective exacerbation
Anaemia
Emergency Department HMO education series
2012
Exam amp investigationshellip
Unwell RR 36 T 368 HR 90 SR BP 180102
Satrsquos 88 RA
Evidence of work of breathing and use of accessory muscles (which are these)
Pursed lip breathing
Prolonged expiration with wheeze
ABG pH 728 pCO2 60 pO2 55 HCO3 26
What do these show
Do you want a CXR
Emergency Department HMO education series
2012
Emergency Department HMO education series
2012
Diagnosis
Acute cardiac failure ndash APO
Most likely cause
Treatment
ECG ndash filed unsigned and
unseen
Emergency Department HMO education series
2012
Diagnosis
Acute cardiac failure ndash APO
Most likely cause
Treatment
Emergency Department HMO education series
2012
Diagnosis - APO
Acute cardiac failure
Treatment
Medications Nitroglycerin SL topical or IV titrated to avoid hypotension Most rapidly
venodilates reduces LV afterload and corrects myocardial ischaemia
Frusemide IV Despite universal use absolute efficacy is unclear
Ventilatory Assistance Non-invasive ventilation (NIV) reduces mortality by 40 particularly with CPAP
and reduces need to intubate
Emergency Department HMO education series
2012
Case C2 - Male in 60rsquos
Progressive SOB over 6 months worse over 24 hours
Orthopnoea Paroxysmal nocturnal dyspnoea (PND) SOA All present to a minor degree over the 6 months but worse for 24 hours
Palpitations (last 24 hours)
Previous AMI 4 years ago pace maker
Ex-smoker Hypertension (HT) diabetes
Emergency Department HMO education series
2012
Examination
Unwell looking with increased work of breathing
RR 26 afeb HR Irreg 130 BP 10070
Sat 90 RA
JVP 5cm
SOA ++
Displaced apex beat no cardiac murmurs 3rd heart sound present
Normal chest expansion but stony dull percussion in the bases (RgtL) bilateral inspiratory crepitations just above the dull areas
ECG ndash what is your diagnosis
Emergency Department HMO education series
2012
Cardiac failure
Emergency Department HMO education series
2012
Case C2 - Summary
Long standing heart failure with an acute
exacerbation due to new onset rapid AF
Treatment of AF amp heart failure
Antithrombotic strategy
Then rate control
Perhaps rhythm control
See review article re AF treatment
To be published early 2013 Australian Rural Doctor
Case D
Mid 60s male
Found SOB ++ in street
Ambulance called
In ED
SOB at rest
Doesnt want help
Funny smell
Further information
Dishevelled
HR 120 reg BP 9560 Sats 94 RA
Vomiting intermittently
What will you do
Further treatment and
investigation
Further history from patient and collateral
sources
Resuscitation
IV access fluids
Bloods ndash FBC UEC CMP Blood gas
pH 71 pCO2 20 pO2 90 HCO3 10 BE -16
Further treatment and
investigation
Further history from patient and collateral
sources
Resuscitation
IV access fluids
Bloods ndash FBC UEC CMP Blood gas
pH 71 pCO2 20 pO2 90 HCO3 10 BE -16
BSL gt30
Further treatment and
investigation
Treatment
IV fluids ndash caution with Na and cerebral oedema
IV insulin
001 ndash 01 unitskghr
aim for BSL 2mmolL drop per hour
Continue until metabolic correction
Monitor and correct K+ other electrolytes
Monitor urine ketones VBGABG
Identify precipitant
Resolution
Wife arrives and is relieved to find husband
Chairman of Rotary Club
UTI developed whilst wife away for weekend
Questions
Summary
Diagnosis of the breathless patient requires you to look for clueshellip The time course of the illness
Associated symptoms
Known diseases or risk factors for disease
Treatment of illnesses supported by evidence for pneumonia asthma PE AF etc
Interpretation of radiology best done with clinical context
Thankyou
Emergency Department HMO education series
2012
What else should I ask
Travel historyhellip
Other important symptoms of respiratory
disease
Cough
Acute
Chronic
Haemoptysis (cancer TB other infections)
Chest Pain
Daytime sleepiness (obstructive sleep apnea)
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Emergency Department HMO education series
2012
On review
Child becomes distressed when you
approach and attempt to examine
Emergency Department HMO education series
2012
On review
Child becomes distressed when you
approach and attempt to examine
St Gurnasty Infirmary Unpleasantshire Hospitals
Services Trust
Kill or be killed
On review
Child becomes distressed when you
approach and attempt to examine
Intercostal recession marked
Tracheal tug noted
Also note respiratory rate O2 requirements
Emergency Department HMO education series
2013
text
Croup
Emergency Department HMO education series
2013
Treatment
Steroids have been shown to decrease the length of hospital stay need for nebulised Adrenaline and
other interventions
Mild to Moderate Croup
Prednisolone 1mgkg AND prescribe a second dose for the next evening OR a single dose of
Oral Dexamethasone 015mgkg Observe for half an hour post steroid administration Discharge
once stridor-free at rest
Severe croup
Nebulised adrenaline (1 mL of 1 adrenaline diluted to 4 ml with Normal Saline or 5ml of adrenaline
11000)
AND
Give 06mgkg (max 12mg) IMIV dexamethasone
Emergency Department HMO education series
2013
Case B
22 yo man
Brought to the ED by his partner
Sudden onset of SOB
Now present for few hours
How is your differential diagnosis affected by
the sudden onset
Emergency Department HMO education series
2013
Further history
Previously well smokes 10 cigarettesday
Left sided chest pain
Moderate
Pleuritic
Started with the SOB
Is there anything else you would like to ask
What is your differential diagnosis
Emergency Department HMO education series
2013
Emergency Department HMO education series
2012
Differential diagnosis
Pneumothorax
Arrhythmia
Pulmonary Embolism
Asthma (less likely)
Pneumonia
Anxiety
Emergency Department HMO education series
2012
Differential diagnosis
Pneumothorax
Arrhythmia
Pulmonary Embolism
Asthma (less likely)
Pneumonia
Anxiety (Imagine that being your diagnosis and you missed a pound$^ your honour)
You horrible
little doctor
Emergency Department HMO education series
2012
Examination findings
Looks unwell quite distressed with WOB
RR 26 HR 125 SR BP 8060 afebrile
Saturation 93 RA (room air)
Trachea midline
chest expansion on the left
Hyper-resonant percussion note on the left
air entry left lung
What is going on
Is this serious
What is your immediate management
Emergency Department HMO education series
2012
Describe this CXR
Emergency Department HMO education series
2012
Describe this CXR
gt or lt 2cm
Where gt 2cm then pneumothorax is gt50 and is considered large
Emergency Department HMO education series
2012
Describe this CXR
Bigger image next slide
Tethered
lung
gt2cm
Right shift of
mediastinum
Air next to
pericardium
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)
Tension
bullLarge bore cannula 2nd intercostal space mid-clavicular line
If large non-tension
bullgt2cm rim (ie gt50)
bull14-18 G cannula safe triangle (or 2ICS if contraindicated) - aspirate
bullDrain 8-14 FG is usually adequate although 28 FG may be required with
mechanical ventilation
Other considerations
bullNo improvement with drain ndash suction cardiothoracic involvement
httpthoraxbmjcomcontent58suppl_2ii39full
httpssecurecollemergencymedacukcodedocumentaspID=6194
Describe the treatment for
Pneumothorax
httpwwwbrit-thoracicorgukPortals0GuidelinesPleuralDiseaseGuidelinesPleural20Guideline202010Pleural20disease20201020pneumothoraxpdf
Emergency Department HMO education series
2012
Case B2
22 yo 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
Emergency Department HMO education series
2012
Further history amp 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
11070
Sat 97 RA
Widespread wheeze
(what causes this
sound)
Emergency Department HMO education series
2012
Investigations
If the CXR is normal (ish)hellip
Peak Flow 250min (how does this help us)
ABG on room air pH 75 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
Emergency Department HMO education series
2012
Investigations
If the CXR is normalhellip
Peak Flow 250min (how does this help us)
ABG on room air pH 75 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
Emergency Department HMO education series
2012
BBH Asthma protocol
Emergency Department HMO education series
2012
Investigations
If the CXR is normalhellip
Peak Flow 250min (how does this help us)
ABG on room air pH 75 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
Emergency Department HMO education series
2012
Investigations
If the CXR is normalhellip
Peak Flow 300min (how does this help us)
ABG on room air pH 75 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
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 httpwwwnationalasthmaorgauhealth-professionalstools-for-primary-careasthma-action-plansasthma-action-
plan-library
Asthma sticker
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 httpwwwnationalasthmaorgauhealth-professionalstools-for-primary-careasthma-action-plansasthma-action-plan-
library
Discharge checklist
Follow up referral letter to GP
Copy of letter with patient (optional)
Current asthma action plan
Triggers identified
Medications prescribed including
Relievers-short acting B agonists
Preventers-steroids
Symptom controllers-long acting B agonists (if prescribed)
Ensure medications will last until arranged review
Spacer or other delivery systems available and patient
understands use and care
Asthma handouts given (patient information fact sheet)
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 httpwwwnationalasthmaorgauhealth-professionalstools-for-primary-careasthma-action-plansasthma-action-
plan-library
Example action plan
Emergency Department HMO education series
2012
Case B3
22 yo man
Brought to the ED by his partner
Gradual onset of SOB
Now present for few hours
What else do you want to know
Emergency Department HMO education series
2012
Further history amp examination
No wheeze
Productive cough
No recent URTI
Childhood asthma (age
3-12) hay fever
No cardiac history
No risk factors for PE
RR 34 HR 110 SR BP
8965
Sat 87 RA
Dull R base with coarse
crackles
Emergency Department HMO education series
2012
Investigations
The CXR is hellip
ABG on room air
pH 730 CO2 55
O2 70 HCO3 18
What do the blood gases
show
How severe is the
problem
Emergency Department HMO education series
2012
What scoring tools for
pneumonia
SMARTCOP CURB-65 Sepsis guidelines
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
SMARTCOP
SMARTCOP
SMARTCOP
CURB 65
Various website and apps can assist you in
remembering them wwwmdcalccom
Emergency Department HMO education series
2012
Case B4 - Female in her 60rsquos
Sudden onset SOB (present now for 1 hour quite
severe) right sided pleuritic chest pain
Mild fever
Right total knee replacement 3 days ago
persistent leg swelling since yesterday
Non-smoker
No previous cardiorespiratory disease
Emergency Department HMO education series
2012
What is the differential
diagnosis
Emergency Department HMO education series
2012
What is the differential
diagnosis
Most likely
PE
Next likely
Pneumonia
Less likely
Pneumothorax
Arrhythmia
AMI
Emergency Department HMO education series
2012
On examination amp tests
Tachypnoea and some WOB
RR 24 T 376 HR 110 BP 11070
Sats 93 RA
Chest clear with normal percussion and normal breath
sounds
CXR normal
ABG pH 75 CO2 30mmHg p02 62mmHg on RA
Most likely diagnosis
What are Wells criteria
What are Wells criteria
PERC
D-Dimer
What test do you want to do
Emergency Department HMO education series
2012
What can you see
Emergency Department HMO education series
2012
Filling defect R main pulmonary trunk
Emergency Department HMO education series
2012
Emergency Department HMO education series
2012
Case C Man in 60rsquos
Woke this am very SOB and distressed ndash called
ambulance
Progressive SOB over 6 months
Chronic cough
Usually with white sputum
Now worse with no change in sputum colour
No associated fever
SOB in night ndash gets up
Ankles swollen recently
Heavy smoker (35 pack years)
Admission to local hospital 612 ago with chest pains
Emergency Department HMO education series
2012
Differential diagnosis
CCF with acute exacerbation
Chronic obstructive pulmonary disease
(COPD) with acute infective exacerbation
Anaemia
Emergency Department HMO education series
2012
Exam amp investigationshellip
Unwell RR 36 T 368 HR 90 SR BP 180102
Satrsquos 88 RA
Evidence of work of breathing and use of accessory muscles (which are these)
Pursed lip breathing
Prolonged expiration with wheeze
ABG pH 728 pCO2 60 pO2 55 HCO3 26
What do these show
Do you want a CXR
Emergency Department HMO education series
2012
Emergency Department HMO education series
2012
Diagnosis
Acute cardiac failure ndash APO
Most likely cause
Treatment
ECG ndash filed unsigned and
unseen
Emergency Department HMO education series
2012
Diagnosis
Acute cardiac failure ndash APO
Most likely cause
Treatment
Emergency Department HMO education series
2012
Diagnosis - APO
Acute cardiac failure
Treatment
Medications Nitroglycerin SL topical or IV titrated to avoid hypotension Most rapidly
venodilates reduces LV afterload and corrects myocardial ischaemia
Frusemide IV Despite universal use absolute efficacy is unclear
Ventilatory Assistance Non-invasive ventilation (NIV) reduces mortality by 40 particularly with CPAP
and reduces need to intubate
Emergency Department HMO education series
2012
Case C2 - Male in 60rsquos
Progressive SOB over 6 months worse over 24 hours
Orthopnoea Paroxysmal nocturnal dyspnoea (PND) SOA All present to a minor degree over the 6 months but worse for 24 hours
Palpitations (last 24 hours)
Previous AMI 4 years ago pace maker
Ex-smoker Hypertension (HT) diabetes
Emergency Department HMO education series
2012
Examination
Unwell looking with increased work of breathing
RR 26 afeb HR Irreg 130 BP 10070
Sat 90 RA
JVP 5cm
SOA ++
Displaced apex beat no cardiac murmurs 3rd heart sound present
Normal chest expansion but stony dull percussion in the bases (RgtL) bilateral inspiratory crepitations just above the dull areas
ECG ndash what is your diagnosis
Emergency Department HMO education series
2012
Cardiac failure
Emergency Department HMO education series
2012
Case C2 - Summary
Long standing heart failure with an acute
exacerbation due to new onset rapid AF
Treatment of AF amp heart failure
Antithrombotic strategy
Then rate control
Perhaps rhythm control
See review article re AF treatment
To be published early 2013 Australian Rural Doctor
Case D
Mid 60s male
Found SOB ++ in street
Ambulance called
In ED
SOB at rest
Doesnt want help
Funny smell
Further information
Dishevelled
HR 120 reg BP 9560 Sats 94 RA
Vomiting intermittently
What will you do
Further treatment and
investigation
Further history from patient and collateral
sources
Resuscitation
IV access fluids
Bloods ndash FBC UEC CMP Blood gas
pH 71 pCO2 20 pO2 90 HCO3 10 BE -16
Further treatment and
investigation
Further history from patient and collateral
sources
Resuscitation
IV access fluids
Bloods ndash FBC UEC CMP Blood gas
pH 71 pCO2 20 pO2 90 HCO3 10 BE -16
BSL gt30
Further treatment and
investigation
Treatment
IV fluids ndash caution with Na and cerebral oedema
IV insulin
001 ndash 01 unitskghr
aim for BSL 2mmolL drop per hour
Continue until metabolic correction
Monitor and correct K+ other electrolytes
Monitor urine ketones VBGABG
Identify precipitant
Resolution
Wife arrives and is relieved to find husband
Chairman of Rotary Club
UTI developed whilst wife away for weekend
Questions
Summary
Diagnosis of the breathless patient requires you to look for clueshellip The time course of the illness
Associated symptoms
Known diseases or risk factors for disease
Treatment of illnesses supported by evidence for pneumonia asthma PE AF etc
Interpretation of radiology best done with clinical context
Thankyou
Emergency Department HMO education series
2012
What else should I ask
Travel historyhellip
Other important symptoms of respiratory
disease
Cough
Acute
Chronic
Haemoptysis (cancer TB other infections)
Chest Pain
Daytime sleepiness (obstructive sleep apnea)
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Emergency Department HMO education series
2012
On review
Child becomes distressed when you
approach and attempt to examine
St Gurnasty Infirmary Unpleasantshire Hospitals
Services Trust
Kill or be killed
On review
Child becomes distressed when you
approach and attempt to examine
Intercostal recession marked
Tracheal tug noted
Also note respiratory rate O2 requirements
Emergency Department HMO education series
2013
text
Croup
Emergency Department HMO education series
2013
Treatment
Steroids have been shown to decrease the length of hospital stay need for nebulised Adrenaline and
other interventions
Mild to Moderate Croup
Prednisolone 1mgkg AND prescribe a second dose for the next evening OR a single dose of
Oral Dexamethasone 015mgkg Observe for half an hour post steroid administration Discharge
once stridor-free at rest
Severe croup
Nebulised adrenaline (1 mL of 1 adrenaline diluted to 4 ml with Normal Saline or 5ml of adrenaline
11000)
AND
Give 06mgkg (max 12mg) IMIV dexamethasone
Emergency Department HMO education series
2013
Case B
22 yo man
Brought to the ED by his partner
Sudden onset of SOB
Now present for few hours
How is your differential diagnosis affected by
the sudden onset
Emergency Department HMO education series
2013
Further history
Previously well smokes 10 cigarettesday
Left sided chest pain
Moderate
Pleuritic
Started with the SOB
Is there anything else you would like to ask
What is your differential diagnosis
Emergency Department HMO education series
2013
Emergency Department HMO education series
2012
Differential diagnosis
Pneumothorax
Arrhythmia
Pulmonary Embolism
Asthma (less likely)
Pneumonia
Anxiety
Emergency Department HMO education series
2012
Differential diagnosis
Pneumothorax
Arrhythmia
Pulmonary Embolism
Asthma (less likely)
Pneumonia
Anxiety (Imagine that being your diagnosis and you missed a pound$^ your honour)
You horrible
little doctor
Emergency Department HMO education series
2012
Examination findings
Looks unwell quite distressed with WOB
RR 26 HR 125 SR BP 8060 afebrile
Saturation 93 RA (room air)
Trachea midline
chest expansion on the left
Hyper-resonant percussion note on the left
air entry left lung
What is going on
Is this serious
What is your immediate management
Emergency Department HMO education series
2012
Describe this CXR
Emergency Department HMO education series
2012
Describe this CXR
gt or lt 2cm
Where gt 2cm then pneumothorax is gt50 and is considered large
Emergency Department HMO education series
2012
Describe this CXR
Bigger image next slide
Tethered
lung
gt2cm
Right shift of
mediastinum
Air next to
pericardium
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)
Tension
bullLarge bore cannula 2nd intercostal space mid-clavicular line
If large non-tension
bullgt2cm rim (ie gt50)
bull14-18 G cannula safe triangle (or 2ICS if contraindicated) - aspirate
bullDrain 8-14 FG is usually adequate although 28 FG may be required with
mechanical ventilation
Other considerations
bullNo improvement with drain ndash suction cardiothoracic involvement
httpthoraxbmjcomcontent58suppl_2ii39full
httpssecurecollemergencymedacukcodedocumentaspID=6194
Describe the treatment for
Pneumothorax
httpwwwbrit-thoracicorgukPortals0GuidelinesPleuralDiseaseGuidelinesPleural20Guideline202010Pleural20disease20201020pneumothoraxpdf
Emergency Department HMO education series
2012
Case B2
22 yo 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
Emergency Department HMO education series
2012
Further history amp 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
11070
Sat 97 RA
Widespread wheeze
(what causes this
sound)
Emergency Department HMO education series
2012
Investigations
If the CXR is normal (ish)hellip
Peak Flow 250min (how does this help us)
ABG on room air pH 75 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
Emergency Department HMO education series
2012
Investigations
If the CXR is normalhellip
Peak Flow 250min (how does this help us)
ABG on room air pH 75 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
Emergency Department HMO education series
2012
BBH Asthma protocol
Emergency Department HMO education series
2012
Investigations
If the CXR is normalhellip
Peak Flow 250min (how does this help us)
ABG on room air pH 75 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
Emergency Department HMO education series
2012
Investigations
If the CXR is normalhellip
Peak Flow 300min (how does this help us)
ABG on room air pH 75 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
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 httpwwwnationalasthmaorgauhealth-professionalstools-for-primary-careasthma-action-plansasthma-action-
plan-library
Asthma sticker
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 httpwwwnationalasthmaorgauhealth-professionalstools-for-primary-careasthma-action-plansasthma-action-plan-
library
Discharge checklist
Follow up referral letter to GP
Copy of letter with patient (optional)
Current asthma action plan
Triggers identified
Medications prescribed including
Relievers-short acting B agonists
Preventers-steroids
Symptom controllers-long acting B agonists (if prescribed)
Ensure medications will last until arranged review
Spacer or other delivery systems available and patient
understands use and care
Asthma handouts given (patient information fact sheet)
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 httpwwwnationalasthmaorgauhealth-professionalstools-for-primary-careasthma-action-plansasthma-action-
plan-library
Example action plan
Emergency Department HMO education series
2012
Case B3
22 yo man
Brought to the ED by his partner
Gradual onset of SOB
Now present for few hours
What else do you want to know
Emergency Department HMO education series
2012
Further history amp examination
No wheeze
Productive cough
No recent URTI
Childhood asthma (age
3-12) hay fever
No cardiac history
No risk factors for PE
RR 34 HR 110 SR BP
8965
Sat 87 RA
Dull R base with coarse
crackles
Emergency Department HMO education series
2012
Investigations
The CXR is hellip
ABG on room air
pH 730 CO2 55
O2 70 HCO3 18
What do the blood gases
show
How severe is the
problem
Emergency Department HMO education series
2012
What scoring tools for
pneumonia
SMARTCOP CURB-65 Sepsis guidelines
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
SMARTCOP
SMARTCOP
SMARTCOP
CURB 65
Various website and apps can assist you in
remembering them wwwmdcalccom
Emergency Department HMO education series
2012
Case B4 - Female in her 60rsquos
Sudden onset SOB (present now for 1 hour quite
severe) right sided pleuritic chest pain
Mild fever
Right total knee replacement 3 days ago
persistent leg swelling since yesterday
Non-smoker
No previous cardiorespiratory disease
Emergency Department HMO education series
2012
What is the differential
diagnosis
Emergency Department HMO education series
2012
What is the differential
diagnosis
Most likely
PE
Next likely
Pneumonia
Less likely
Pneumothorax
Arrhythmia
AMI
Emergency Department HMO education series
2012
On examination amp tests
Tachypnoea and some WOB
RR 24 T 376 HR 110 BP 11070
Sats 93 RA
Chest clear with normal percussion and normal breath
sounds
CXR normal
ABG pH 75 CO2 30mmHg p02 62mmHg on RA
Most likely diagnosis
What are Wells criteria
What are Wells criteria
PERC
D-Dimer
What test do you want to do
Emergency Department HMO education series
2012
What can you see
Emergency Department HMO education series
2012
Filling defect R main pulmonary trunk
Emergency Department HMO education series
2012
Emergency Department HMO education series
2012
Case C Man in 60rsquos
Woke this am very SOB and distressed ndash called
ambulance
Progressive SOB over 6 months
Chronic cough
Usually with white sputum
Now worse with no change in sputum colour
No associated fever
SOB in night ndash gets up
Ankles swollen recently
Heavy smoker (35 pack years)
Admission to local hospital 612 ago with chest pains
Emergency Department HMO education series
2012
Differential diagnosis
CCF with acute exacerbation
Chronic obstructive pulmonary disease
(COPD) with acute infective exacerbation
Anaemia
Emergency Department HMO education series
2012
Exam amp investigationshellip
Unwell RR 36 T 368 HR 90 SR BP 180102
Satrsquos 88 RA
Evidence of work of breathing and use of accessory muscles (which are these)
Pursed lip breathing
Prolonged expiration with wheeze
ABG pH 728 pCO2 60 pO2 55 HCO3 26
What do these show
Do you want a CXR
Emergency Department HMO education series
2012
Emergency Department HMO education series
2012
Diagnosis
Acute cardiac failure ndash APO
Most likely cause
Treatment
ECG ndash filed unsigned and
unseen
Emergency Department HMO education series
2012
Diagnosis
Acute cardiac failure ndash APO
Most likely cause
Treatment
Emergency Department HMO education series
2012
Diagnosis - APO
Acute cardiac failure
Treatment
Medications Nitroglycerin SL topical or IV titrated to avoid hypotension Most rapidly
venodilates reduces LV afterload and corrects myocardial ischaemia
Frusemide IV Despite universal use absolute efficacy is unclear
Ventilatory Assistance Non-invasive ventilation (NIV) reduces mortality by 40 particularly with CPAP
and reduces need to intubate
Emergency Department HMO education series
2012
Case C2 - Male in 60rsquos
Progressive SOB over 6 months worse over 24 hours
Orthopnoea Paroxysmal nocturnal dyspnoea (PND) SOA All present to a minor degree over the 6 months but worse for 24 hours
Palpitations (last 24 hours)
Previous AMI 4 years ago pace maker
Ex-smoker Hypertension (HT) diabetes
Emergency Department HMO education series
2012
Examination
Unwell looking with increased work of breathing
RR 26 afeb HR Irreg 130 BP 10070
Sat 90 RA
JVP 5cm
SOA ++
Displaced apex beat no cardiac murmurs 3rd heart sound present
Normal chest expansion but stony dull percussion in the bases (RgtL) bilateral inspiratory crepitations just above the dull areas
ECG ndash what is your diagnosis
Emergency Department HMO education series
2012
Cardiac failure
Emergency Department HMO education series
2012
Case C2 - Summary
Long standing heart failure with an acute
exacerbation due to new onset rapid AF
Treatment of AF amp heart failure
Antithrombotic strategy
Then rate control
Perhaps rhythm control
See review article re AF treatment
To be published early 2013 Australian Rural Doctor
Case D
Mid 60s male
Found SOB ++ in street
Ambulance called
In ED
SOB at rest
Doesnt want help
Funny smell
Further information
Dishevelled
HR 120 reg BP 9560 Sats 94 RA
Vomiting intermittently
What will you do
Further treatment and
investigation
Further history from patient and collateral
sources
Resuscitation
IV access fluids
Bloods ndash FBC UEC CMP Blood gas
pH 71 pCO2 20 pO2 90 HCO3 10 BE -16
Further treatment and
investigation
Further history from patient and collateral
sources
Resuscitation
IV access fluids
Bloods ndash FBC UEC CMP Blood gas
pH 71 pCO2 20 pO2 90 HCO3 10 BE -16
BSL gt30
Further treatment and
investigation
Treatment
IV fluids ndash caution with Na and cerebral oedema
IV insulin
001 ndash 01 unitskghr
aim for BSL 2mmolL drop per hour
Continue until metabolic correction
Monitor and correct K+ other electrolytes
Monitor urine ketones VBGABG
Identify precipitant
Resolution
Wife arrives and is relieved to find husband
Chairman of Rotary Club
UTI developed whilst wife away for weekend
Questions
Summary
Diagnosis of the breathless patient requires you to look for clueshellip The time course of the illness
Associated symptoms
Known diseases or risk factors for disease
Treatment of illnesses supported by evidence for pneumonia asthma PE AF etc
Interpretation of radiology best done with clinical context
Thankyou
Emergency Department HMO education series
2012
What else should I ask
Travel historyhellip
Other important symptoms of respiratory
disease
Cough
Acute
Chronic
Haemoptysis (cancer TB other infections)
Chest Pain
Daytime sleepiness (obstructive sleep apnea)
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
On review
Child becomes distressed when you
approach and attempt to examine
Intercostal recession marked
Tracheal tug noted
Also note respiratory rate O2 requirements
Emergency Department HMO education series
2013
text
Croup
Emergency Department HMO education series
2013
Treatment
Steroids have been shown to decrease the length of hospital stay need for nebulised Adrenaline and
other interventions
Mild to Moderate Croup
Prednisolone 1mgkg AND prescribe a second dose for the next evening OR a single dose of
Oral Dexamethasone 015mgkg Observe for half an hour post steroid administration Discharge
once stridor-free at rest
Severe croup
Nebulised adrenaline (1 mL of 1 adrenaline diluted to 4 ml with Normal Saline or 5ml of adrenaline
11000)
AND
Give 06mgkg (max 12mg) IMIV dexamethasone
Emergency Department HMO education series
2013
Case B
22 yo man
Brought to the ED by his partner
Sudden onset of SOB
Now present for few hours
How is your differential diagnosis affected by
the sudden onset
Emergency Department HMO education series
2013
Further history
Previously well smokes 10 cigarettesday
Left sided chest pain
Moderate
Pleuritic
Started with the SOB
Is there anything else you would like to ask
What is your differential diagnosis
Emergency Department HMO education series
2013
Emergency Department HMO education series
2012
Differential diagnosis
Pneumothorax
Arrhythmia
Pulmonary Embolism
Asthma (less likely)
Pneumonia
Anxiety
Emergency Department HMO education series
2012
Differential diagnosis
Pneumothorax
Arrhythmia
Pulmonary Embolism
Asthma (less likely)
Pneumonia
Anxiety (Imagine that being your diagnosis and you missed a pound$^ your honour)
You horrible
little doctor
Emergency Department HMO education series
2012
Examination findings
Looks unwell quite distressed with WOB
RR 26 HR 125 SR BP 8060 afebrile
Saturation 93 RA (room air)
Trachea midline
chest expansion on the left
Hyper-resonant percussion note on the left
air entry left lung
What is going on
Is this serious
What is your immediate management
Emergency Department HMO education series
2012
Describe this CXR
Emergency Department HMO education series
2012
Describe this CXR
gt or lt 2cm
Where gt 2cm then pneumothorax is gt50 and is considered large
Emergency Department HMO education series
2012
Describe this CXR
Bigger image next slide
Tethered
lung
gt2cm
Right shift of
mediastinum
Air next to
pericardium
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)
Tension
bullLarge bore cannula 2nd intercostal space mid-clavicular line
If large non-tension
bullgt2cm rim (ie gt50)
bull14-18 G cannula safe triangle (or 2ICS if contraindicated) - aspirate
bullDrain 8-14 FG is usually adequate although 28 FG may be required with
mechanical ventilation
Other considerations
bullNo improvement with drain ndash suction cardiothoracic involvement
httpthoraxbmjcomcontent58suppl_2ii39full
httpssecurecollemergencymedacukcodedocumentaspID=6194
Describe the treatment for
Pneumothorax
httpwwwbrit-thoracicorgukPortals0GuidelinesPleuralDiseaseGuidelinesPleural20Guideline202010Pleural20disease20201020pneumothoraxpdf
Emergency Department HMO education series
2012
Case B2
22 yo 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
Emergency Department HMO education series
2012
Further history amp 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
11070
Sat 97 RA
Widespread wheeze
(what causes this
sound)
Emergency Department HMO education series
2012
Investigations
If the CXR is normal (ish)hellip
Peak Flow 250min (how does this help us)
ABG on room air pH 75 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
Emergency Department HMO education series
2012
Investigations
If the CXR is normalhellip
Peak Flow 250min (how does this help us)
ABG on room air pH 75 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
Emergency Department HMO education series
2012
BBH Asthma protocol
Emergency Department HMO education series
2012
Investigations
If the CXR is normalhellip
Peak Flow 250min (how does this help us)
ABG on room air pH 75 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
Emergency Department HMO education series
2012
Investigations
If the CXR is normalhellip
Peak Flow 300min (how does this help us)
ABG on room air pH 75 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
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 httpwwwnationalasthmaorgauhealth-professionalstools-for-primary-careasthma-action-plansasthma-action-
plan-library
Asthma sticker
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 httpwwwnationalasthmaorgauhealth-professionalstools-for-primary-careasthma-action-plansasthma-action-plan-
library
Discharge checklist
Follow up referral letter to GP
Copy of letter with patient (optional)
Current asthma action plan
Triggers identified
Medications prescribed including
Relievers-short acting B agonists
Preventers-steroids
Symptom controllers-long acting B agonists (if prescribed)
Ensure medications will last until arranged review
Spacer or other delivery systems available and patient
understands use and care
Asthma handouts given (patient information fact sheet)
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 httpwwwnationalasthmaorgauhealth-professionalstools-for-primary-careasthma-action-plansasthma-action-
plan-library
Example action plan
Emergency Department HMO education series
2012
Case B3
22 yo man
Brought to the ED by his partner
Gradual onset of SOB
Now present for few hours
What else do you want to know
Emergency Department HMO education series
2012
Further history amp examination
No wheeze
Productive cough
No recent URTI
Childhood asthma (age
3-12) hay fever
No cardiac history
No risk factors for PE
RR 34 HR 110 SR BP
8965
Sat 87 RA
Dull R base with coarse
crackles
Emergency Department HMO education series
2012
Investigations
The CXR is hellip
ABG on room air
pH 730 CO2 55
O2 70 HCO3 18
What do the blood gases
show
How severe is the
problem
Emergency Department HMO education series
2012
What scoring tools for
pneumonia
SMARTCOP CURB-65 Sepsis guidelines
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
SMARTCOP
SMARTCOP
SMARTCOP
CURB 65
Various website and apps can assist you in
remembering them wwwmdcalccom
Emergency Department HMO education series
2012
Case B4 - Female in her 60rsquos
Sudden onset SOB (present now for 1 hour quite
severe) right sided pleuritic chest pain
Mild fever
Right total knee replacement 3 days ago
persistent leg swelling since yesterday
Non-smoker
No previous cardiorespiratory disease
Emergency Department HMO education series
2012
What is the differential
diagnosis
Emergency Department HMO education series
2012
What is the differential
diagnosis
Most likely
PE
Next likely
Pneumonia
Less likely
Pneumothorax
Arrhythmia
AMI
Emergency Department HMO education series
2012
On examination amp tests
Tachypnoea and some WOB
RR 24 T 376 HR 110 BP 11070
Sats 93 RA
Chest clear with normal percussion and normal breath
sounds
CXR normal
ABG pH 75 CO2 30mmHg p02 62mmHg on RA
Most likely diagnosis
What are Wells criteria
What are Wells criteria
PERC
D-Dimer
What test do you want to do
Emergency Department HMO education series
2012
What can you see
Emergency Department HMO education series
2012
Filling defect R main pulmonary trunk
Emergency Department HMO education series
2012
Emergency Department HMO education series
2012
Case C Man in 60rsquos
Woke this am very SOB and distressed ndash called
ambulance
Progressive SOB over 6 months
Chronic cough
Usually with white sputum
Now worse with no change in sputum colour
No associated fever
SOB in night ndash gets up
Ankles swollen recently
Heavy smoker (35 pack years)
Admission to local hospital 612 ago with chest pains
Emergency Department HMO education series
2012
Differential diagnosis
CCF with acute exacerbation
Chronic obstructive pulmonary disease
(COPD) with acute infective exacerbation
Anaemia
Emergency Department HMO education series
2012
Exam amp investigationshellip
Unwell RR 36 T 368 HR 90 SR BP 180102
Satrsquos 88 RA
Evidence of work of breathing and use of accessory muscles (which are these)
Pursed lip breathing
Prolonged expiration with wheeze
ABG pH 728 pCO2 60 pO2 55 HCO3 26
What do these show
Do you want a CXR
Emergency Department HMO education series
2012
Emergency Department HMO education series
2012
Diagnosis
Acute cardiac failure ndash APO
Most likely cause
Treatment
ECG ndash filed unsigned and
unseen
Emergency Department HMO education series
2012
Diagnosis
Acute cardiac failure ndash APO
Most likely cause
Treatment
Emergency Department HMO education series
2012
Diagnosis - APO
Acute cardiac failure
Treatment
Medications Nitroglycerin SL topical or IV titrated to avoid hypotension Most rapidly
venodilates reduces LV afterload and corrects myocardial ischaemia
Frusemide IV Despite universal use absolute efficacy is unclear
Ventilatory Assistance Non-invasive ventilation (NIV) reduces mortality by 40 particularly with CPAP
and reduces need to intubate
Emergency Department HMO education series
2012
Case C2 - Male in 60rsquos
Progressive SOB over 6 months worse over 24 hours
Orthopnoea Paroxysmal nocturnal dyspnoea (PND) SOA All present to a minor degree over the 6 months but worse for 24 hours
Palpitations (last 24 hours)
Previous AMI 4 years ago pace maker
Ex-smoker Hypertension (HT) diabetes
Emergency Department HMO education series
2012
Examination
Unwell looking with increased work of breathing
RR 26 afeb HR Irreg 130 BP 10070
Sat 90 RA
JVP 5cm
SOA ++
Displaced apex beat no cardiac murmurs 3rd heart sound present
Normal chest expansion but stony dull percussion in the bases (RgtL) bilateral inspiratory crepitations just above the dull areas
ECG ndash what is your diagnosis
Emergency Department HMO education series
2012
Cardiac failure
Emergency Department HMO education series
2012
Case C2 - Summary
Long standing heart failure with an acute
exacerbation due to new onset rapid AF
Treatment of AF amp heart failure
Antithrombotic strategy
Then rate control
Perhaps rhythm control
See review article re AF treatment
To be published early 2013 Australian Rural Doctor
Case D
Mid 60s male
Found SOB ++ in street
Ambulance called
In ED
SOB at rest
Doesnt want help
Funny smell
Further information
Dishevelled
HR 120 reg BP 9560 Sats 94 RA
Vomiting intermittently
What will you do
Further treatment and
investigation
Further history from patient and collateral
sources
Resuscitation
IV access fluids
Bloods ndash FBC UEC CMP Blood gas
pH 71 pCO2 20 pO2 90 HCO3 10 BE -16
Further treatment and
investigation
Further history from patient and collateral
sources
Resuscitation
IV access fluids
Bloods ndash FBC UEC CMP Blood gas
pH 71 pCO2 20 pO2 90 HCO3 10 BE -16
BSL gt30
Further treatment and
investigation
Treatment
IV fluids ndash caution with Na and cerebral oedema
IV insulin
001 ndash 01 unitskghr
aim for BSL 2mmolL drop per hour
Continue until metabolic correction
Monitor and correct K+ other electrolytes
Monitor urine ketones VBGABG
Identify precipitant
Resolution
Wife arrives and is relieved to find husband
Chairman of Rotary Club
UTI developed whilst wife away for weekend
Questions
Summary
Diagnosis of the breathless patient requires you to look for clueshellip The time course of the illness
Associated symptoms
Known diseases or risk factors for disease
Treatment of illnesses supported by evidence for pneumonia asthma PE AF etc
Interpretation of radiology best done with clinical context
Thankyou
Emergency Department HMO education series
2012
What else should I ask
Travel historyhellip
Other important symptoms of respiratory
disease
Cough
Acute
Chronic
Haemoptysis (cancer TB other infections)
Chest Pain
Daytime sleepiness (obstructive sleep apnea)
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
text
Croup
Emergency Department HMO education series
2013
Treatment
Steroids have been shown to decrease the length of hospital stay need for nebulised Adrenaline and
other interventions
Mild to Moderate Croup
Prednisolone 1mgkg AND prescribe a second dose for the next evening OR a single dose of
Oral Dexamethasone 015mgkg Observe for half an hour post steroid administration Discharge
once stridor-free at rest
Severe croup
Nebulised adrenaline (1 mL of 1 adrenaline diluted to 4 ml with Normal Saline or 5ml of adrenaline
11000)
AND
Give 06mgkg (max 12mg) IMIV dexamethasone
Emergency Department HMO education series
2013
Case B
22 yo man
Brought to the ED by his partner
Sudden onset of SOB
Now present for few hours
How is your differential diagnosis affected by
the sudden onset
Emergency Department HMO education series
2013
Further history
Previously well smokes 10 cigarettesday
Left sided chest pain
Moderate
Pleuritic
Started with the SOB
Is there anything else you would like to ask
What is your differential diagnosis
Emergency Department HMO education series
2013
Emergency Department HMO education series
2012
Differential diagnosis
Pneumothorax
Arrhythmia
Pulmonary Embolism
Asthma (less likely)
Pneumonia
Anxiety
Emergency Department HMO education series
2012
Differential diagnosis
Pneumothorax
Arrhythmia
Pulmonary Embolism
Asthma (less likely)
Pneumonia
Anxiety (Imagine that being your diagnosis and you missed a pound$^ your honour)
You horrible
little doctor
Emergency Department HMO education series
2012
Examination findings
Looks unwell quite distressed with WOB
RR 26 HR 125 SR BP 8060 afebrile
Saturation 93 RA (room air)
Trachea midline
chest expansion on the left
Hyper-resonant percussion note on the left
air entry left lung
What is going on
Is this serious
What is your immediate management
Emergency Department HMO education series
2012
Describe this CXR
Emergency Department HMO education series
2012
Describe this CXR
gt or lt 2cm
Where gt 2cm then pneumothorax is gt50 and is considered large
Emergency Department HMO education series
2012
Describe this CXR
Bigger image next slide
Tethered
lung
gt2cm
Right shift of
mediastinum
Air next to
pericardium
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)
Tension
bullLarge bore cannula 2nd intercostal space mid-clavicular line
If large non-tension
bullgt2cm rim (ie gt50)
bull14-18 G cannula safe triangle (or 2ICS if contraindicated) - aspirate
bullDrain 8-14 FG is usually adequate although 28 FG may be required with
mechanical ventilation
Other considerations
bullNo improvement with drain ndash suction cardiothoracic involvement
httpthoraxbmjcomcontent58suppl_2ii39full
httpssecurecollemergencymedacukcodedocumentaspID=6194
Describe the treatment for
Pneumothorax
httpwwwbrit-thoracicorgukPortals0GuidelinesPleuralDiseaseGuidelinesPleural20Guideline202010Pleural20disease20201020pneumothoraxpdf
Emergency Department HMO education series
2012
Case B2
22 yo 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
Emergency Department HMO education series
2012
Further history amp 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
11070
Sat 97 RA
Widespread wheeze
(what causes this
sound)
Emergency Department HMO education series
2012
Investigations
If the CXR is normal (ish)hellip
Peak Flow 250min (how does this help us)
ABG on room air pH 75 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
Emergency Department HMO education series
2012
Investigations
If the CXR is normalhellip
Peak Flow 250min (how does this help us)
ABG on room air pH 75 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
Emergency Department HMO education series
2012
BBH Asthma protocol
Emergency Department HMO education series
2012
Investigations
If the CXR is normalhellip
Peak Flow 250min (how does this help us)
ABG on room air pH 75 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
Emergency Department HMO education series
2012
Investigations
If the CXR is normalhellip
Peak Flow 300min (how does this help us)
ABG on room air pH 75 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
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 httpwwwnationalasthmaorgauhealth-professionalstools-for-primary-careasthma-action-plansasthma-action-
plan-library
Asthma sticker
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 httpwwwnationalasthmaorgauhealth-professionalstools-for-primary-careasthma-action-plansasthma-action-plan-
library
Discharge checklist
Follow up referral letter to GP
Copy of letter with patient (optional)
Current asthma action plan
Triggers identified
Medications prescribed including
Relievers-short acting B agonists
Preventers-steroids
Symptom controllers-long acting B agonists (if prescribed)
Ensure medications will last until arranged review
Spacer or other delivery systems available and patient
understands use and care
Asthma handouts given (patient information fact sheet)
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 httpwwwnationalasthmaorgauhealth-professionalstools-for-primary-careasthma-action-plansasthma-action-
plan-library
Example action plan
Emergency Department HMO education series
2012
Case B3
22 yo man
Brought to the ED by his partner
Gradual onset of SOB
Now present for few hours
What else do you want to know
Emergency Department HMO education series
2012
Further history amp examination
No wheeze
Productive cough
No recent URTI
Childhood asthma (age
3-12) hay fever
No cardiac history
No risk factors for PE
RR 34 HR 110 SR BP
8965
Sat 87 RA
Dull R base with coarse
crackles
Emergency Department HMO education series
2012
Investigations
The CXR is hellip
ABG on room air
pH 730 CO2 55
O2 70 HCO3 18
What do the blood gases
show
How severe is the
problem
Emergency Department HMO education series
2012
What scoring tools for
pneumonia
SMARTCOP CURB-65 Sepsis guidelines
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
SMARTCOP
SMARTCOP
SMARTCOP
CURB 65
Various website and apps can assist you in
remembering them wwwmdcalccom
Emergency Department HMO education series
2012
Case B4 - Female in her 60rsquos
Sudden onset SOB (present now for 1 hour quite
severe) right sided pleuritic chest pain
Mild fever
Right total knee replacement 3 days ago
persistent leg swelling since yesterday
Non-smoker
No previous cardiorespiratory disease
Emergency Department HMO education series
2012
What is the differential
diagnosis
Emergency Department HMO education series
2012
What is the differential
diagnosis
Most likely
PE
Next likely
Pneumonia
Less likely
Pneumothorax
Arrhythmia
AMI
Emergency Department HMO education series
2012
On examination amp tests
Tachypnoea and some WOB
RR 24 T 376 HR 110 BP 11070
Sats 93 RA
Chest clear with normal percussion and normal breath
sounds
CXR normal
ABG pH 75 CO2 30mmHg p02 62mmHg on RA
Most likely diagnosis
What are Wells criteria
What are Wells criteria
PERC
D-Dimer
What test do you want to do
Emergency Department HMO education series
2012
What can you see
Emergency Department HMO education series
2012
Filling defect R main pulmonary trunk
Emergency Department HMO education series
2012
Emergency Department HMO education series
2012
Case C Man in 60rsquos
Woke this am very SOB and distressed ndash called
ambulance
Progressive SOB over 6 months
Chronic cough
Usually with white sputum
Now worse with no change in sputum colour
No associated fever
SOB in night ndash gets up
Ankles swollen recently
Heavy smoker (35 pack years)
Admission to local hospital 612 ago with chest pains
Emergency Department HMO education series
2012
Differential diagnosis
CCF with acute exacerbation
Chronic obstructive pulmonary disease
(COPD) with acute infective exacerbation
Anaemia
Emergency Department HMO education series
2012
Exam amp investigationshellip
Unwell RR 36 T 368 HR 90 SR BP 180102
Satrsquos 88 RA
Evidence of work of breathing and use of accessory muscles (which are these)
Pursed lip breathing
Prolonged expiration with wheeze
ABG pH 728 pCO2 60 pO2 55 HCO3 26
What do these show
Do you want a CXR
Emergency Department HMO education series
2012
Emergency Department HMO education series
2012
Diagnosis
Acute cardiac failure ndash APO
Most likely cause
Treatment
ECG ndash filed unsigned and
unseen
Emergency Department HMO education series
2012
Diagnosis
Acute cardiac failure ndash APO
Most likely cause
Treatment
Emergency Department HMO education series
2012
Diagnosis - APO
Acute cardiac failure
Treatment
Medications Nitroglycerin SL topical or IV titrated to avoid hypotension Most rapidly
venodilates reduces LV afterload and corrects myocardial ischaemia
Frusemide IV Despite universal use absolute efficacy is unclear
Ventilatory Assistance Non-invasive ventilation (NIV) reduces mortality by 40 particularly with CPAP
and reduces need to intubate
Emergency Department HMO education series
2012
Case C2 - Male in 60rsquos
Progressive SOB over 6 months worse over 24 hours
Orthopnoea Paroxysmal nocturnal dyspnoea (PND) SOA All present to a minor degree over the 6 months but worse for 24 hours
Palpitations (last 24 hours)
Previous AMI 4 years ago pace maker
Ex-smoker Hypertension (HT) diabetes
Emergency Department HMO education series
2012
Examination
Unwell looking with increased work of breathing
RR 26 afeb HR Irreg 130 BP 10070
Sat 90 RA
JVP 5cm
SOA ++
Displaced apex beat no cardiac murmurs 3rd heart sound present
Normal chest expansion but stony dull percussion in the bases (RgtL) bilateral inspiratory crepitations just above the dull areas
ECG ndash what is your diagnosis
Emergency Department HMO education series
2012
Cardiac failure
Emergency Department HMO education series
2012
Case C2 - Summary
Long standing heart failure with an acute
exacerbation due to new onset rapid AF
Treatment of AF amp heart failure
Antithrombotic strategy
Then rate control
Perhaps rhythm control
See review article re AF treatment
To be published early 2013 Australian Rural Doctor
Case D
Mid 60s male
Found SOB ++ in street
Ambulance called
In ED
SOB at rest
Doesnt want help
Funny smell
Further information
Dishevelled
HR 120 reg BP 9560 Sats 94 RA
Vomiting intermittently
What will you do
Further treatment and
investigation
Further history from patient and collateral
sources
Resuscitation
IV access fluids
Bloods ndash FBC UEC CMP Blood gas
pH 71 pCO2 20 pO2 90 HCO3 10 BE -16
Further treatment and
investigation
Further history from patient and collateral
sources
Resuscitation
IV access fluids
Bloods ndash FBC UEC CMP Blood gas
pH 71 pCO2 20 pO2 90 HCO3 10 BE -16
BSL gt30
Further treatment and
investigation
Treatment
IV fluids ndash caution with Na and cerebral oedema
IV insulin
001 ndash 01 unitskghr
aim for BSL 2mmolL drop per hour
Continue until metabolic correction
Monitor and correct K+ other electrolytes
Monitor urine ketones VBGABG
Identify precipitant
Resolution
Wife arrives and is relieved to find husband
Chairman of Rotary Club
UTI developed whilst wife away for weekend
Questions
Summary
Diagnosis of the breathless patient requires you to look for clueshellip The time course of the illness
Associated symptoms
Known diseases or risk factors for disease
Treatment of illnesses supported by evidence for pneumonia asthma PE AF etc
Interpretation of radiology best done with clinical context
Thankyou
Emergency Department HMO education series
2012
What else should I ask
Travel historyhellip
Other important symptoms of respiratory
disease
Cough
Acute
Chronic
Haemoptysis (cancer TB other infections)
Chest Pain
Daytime sleepiness (obstructive sleep apnea)
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Treatment
Steroids have been shown to decrease the length of hospital stay need for nebulised Adrenaline and
other interventions
Mild to Moderate Croup
Prednisolone 1mgkg AND prescribe a second dose for the next evening OR a single dose of
Oral Dexamethasone 015mgkg Observe for half an hour post steroid administration Discharge
once stridor-free at rest
Severe croup
Nebulised adrenaline (1 mL of 1 adrenaline diluted to 4 ml with Normal Saline or 5ml of adrenaline
11000)
AND
Give 06mgkg (max 12mg) IMIV dexamethasone
Emergency Department HMO education series
2013
Case B
22 yo man
Brought to the ED by his partner
Sudden onset of SOB
Now present for few hours
How is your differential diagnosis affected by
the sudden onset
Emergency Department HMO education series
2013
Further history
Previously well smokes 10 cigarettesday
Left sided chest pain
Moderate
Pleuritic
Started with the SOB
Is there anything else you would like to ask
What is your differential diagnosis
Emergency Department HMO education series
2013
Emergency Department HMO education series
2012
Differential diagnosis
Pneumothorax
Arrhythmia
Pulmonary Embolism
Asthma (less likely)
Pneumonia
Anxiety
Emergency Department HMO education series
2012
Differential diagnosis
Pneumothorax
Arrhythmia
Pulmonary Embolism
Asthma (less likely)
Pneumonia
Anxiety (Imagine that being your diagnosis and you missed a pound$^ your honour)
You horrible
little doctor
Emergency Department HMO education series
2012
Examination findings
Looks unwell quite distressed with WOB
RR 26 HR 125 SR BP 8060 afebrile
Saturation 93 RA (room air)
Trachea midline
chest expansion on the left
Hyper-resonant percussion note on the left
air entry left lung
What is going on
Is this serious
What is your immediate management
Emergency Department HMO education series
2012
Describe this CXR
Emergency Department HMO education series
2012
Describe this CXR
gt or lt 2cm
Where gt 2cm then pneumothorax is gt50 and is considered large
Emergency Department HMO education series
2012
Describe this CXR
Bigger image next slide
Tethered
lung
gt2cm
Right shift of
mediastinum
Air next to
pericardium
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)
Tension
bullLarge bore cannula 2nd intercostal space mid-clavicular line
If large non-tension
bullgt2cm rim (ie gt50)
bull14-18 G cannula safe triangle (or 2ICS if contraindicated) - aspirate
bullDrain 8-14 FG is usually adequate although 28 FG may be required with
mechanical ventilation
Other considerations
bullNo improvement with drain ndash suction cardiothoracic involvement
httpthoraxbmjcomcontent58suppl_2ii39full
httpssecurecollemergencymedacukcodedocumentaspID=6194
Describe the treatment for
Pneumothorax
httpwwwbrit-thoracicorgukPortals0GuidelinesPleuralDiseaseGuidelinesPleural20Guideline202010Pleural20disease20201020pneumothoraxpdf
Emergency Department HMO education series
2012
Case B2
22 yo 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
Emergency Department HMO education series
2012
Further history amp 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
11070
Sat 97 RA
Widespread wheeze
(what causes this
sound)
Emergency Department HMO education series
2012
Investigations
If the CXR is normal (ish)hellip
Peak Flow 250min (how does this help us)
ABG on room air pH 75 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
Emergency Department HMO education series
2012
Investigations
If the CXR is normalhellip
Peak Flow 250min (how does this help us)
ABG on room air pH 75 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
Emergency Department HMO education series
2012
BBH Asthma protocol
Emergency Department HMO education series
2012
Investigations
If the CXR is normalhellip
Peak Flow 250min (how does this help us)
ABG on room air pH 75 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
Emergency Department HMO education series
2012
Investigations
If the CXR is normalhellip
Peak Flow 300min (how does this help us)
ABG on room air pH 75 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
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 httpwwwnationalasthmaorgauhealth-professionalstools-for-primary-careasthma-action-plansasthma-action-
plan-library
Asthma sticker
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 httpwwwnationalasthmaorgauhealth-professionalstools-for-primary-careasthma-action-plansasthma-action-plan-
library
Discharge checklist
Follow up referral letter to GP
Copy of letter with patient (optional)
Current asthma action plan
Triggers identified
Medications prescribed including
Relievers-short acting B agonists
Preventers-steroids
Symptom controllers-long acting B agonists (if prescribed)
Ensure medications will last until arranged review
Spacer or other delivery systems available and patient
understands use and care
Asthma handouts given (patient information fact sheet)
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 httpwwwnationalasthmaorgauhealth-professionalstools-for-primary-careasthma-action-plansasthma-action-
plan-library
Example action plan
Emergency Department HMO education series
2012
Case B3
22 yo man
Brought to the ED by his partner
Gradual onset of SOB
Now present for few hours
What else do you want to know
Emergency Department HMO education series
2012
Further history amp examination
No wheeze
Productive cough
No recent URTI
Childhood asthma (age
3-12) hay fever
No cardiac history
No risk factors for PE
RR 34 HR 110 SR BP
8965
Sat 87 RA
Dull R base with coarse
crackles
Emergency Department HMO education series
2012
Investigations
The CXR is hellip
ABG on room air
pH 730 CO2 55
O2 70 HCO3 18
What do the blood gases
show
How severe is the
problem
Emergency Department HMO education series
2012
What scoring tools for
pneumonia
SMARTCOP CURB-65 Sepsis guidelines
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
SMARTCOP
SMARTCOP
SMARTCOP
CURB 65
Various website and apps can assist you in
remembering them wwwmdcalccom
Emergency Department HMO education series
2012
Case B4 - Female in her 60rsquos
Sudden onset SOB (present now for 1 hour quite
severe) right sided pleuritic chest pain
Mild fever
Right total knee replacement 3 days ago
persistent leg swelling since yesterday
Non-smoker
No previous cardiorespiratory disease
Emergency Department HMO education series
2012
What is the differential
diagnosis
Emergency Department HMO education series
2012
What is the differential
diagnosis
Most likely
PE
Next likely
Pneumonia
Less likely
Pneumothorax
Arrhythmia
AMI
Emergency Department HMO education series
2012
On examination amp tests
Tachypnoea and some WOB
RR 24 T 376 HR 110 BP 11070
Sats 93 RA
Chest clear with normal percussion and normal breath
sounds
CXR normal
ABG pH 75 CO2 30mmHg p02 62mmHg on RA
Most likely diagnosis
What are Wells criteria
What are Wells criteria
PERC
D-Dimer
What test do you want to do
Emergency Department HMO education series
2012
What can you see
Emergency Department HMO education series
2012
Filling defect R main pulmonary trunk
Emergency Department HMO education series
2012
Emergency Department HMO education series
2012
Case C Man in 60rsquos
Woke this am very SOB and distressed ndash called
ambulance
Progressive SOB over 6 months
Chronic cough
Usually with white sputum
Now worse with no change in sputum colour
No associated fever
SOB in night ndash gets up
Ankles swollen recently
Heavy smoker (35 pack years)
Admission to local hospital 612 ago with chest pains
Emergency Department HMO education series
2012
Differential diagnosis
CCF with acute exacerbation
Chronic obstructive pulmonary disease
(COPD) with acute infective exacerbation
Anaemia
Emergency Department HMO education series
2012
Exam amp investigationshellip
Unwell RR 36 T 368 HR 90 SR BP 180102
Satrsquos 88 RA
Evidence of work of breathing and use of accessory muscles (which are these)
Pursed lip breathing
Prolonged expiration with wheeze
ABG pH 728 pCO2 60 pO2 55 HCO3 26
What do these show
Do you want a CXR
Emergency Department HMO education series
2012
Emergency Department HMO education series
2012
Diagnosis
Acute cardiac failure ndash APO
Most likely cause
Treatment
ECG ndash filed unsigned and
unseen
Emergency Department HMO education series
2012
Diagnosis
Acute cardiac failure ndash APO
Most likely cause
Treatment
Emergency Department HMO education series
2012
Diagnosis - APO
Acute cardiac failure
Treatment
Medications Nitroglycerin SL topical or IV titrated to avoid hypotension Most rapidly
venodilates reduces LV afterload and corrects myocardial ischaemia
Frusemide IV Despite universal use absolute efficacy is unclear
Ventilatory Assistance Non-invasive ventilation (NIV) reduces mortality by 40 particularly with CPAP
and reduces need to intubate
Emergency Department HMO education series
2012
Case C2 - Male in 60rsquos
Progressive SOB over 6 months worse over 24 hours
Orthopnoea Paroxysmal nocturnal dyspnoea (PND) SOA All present to a minor degree over the 6 months but worse for 24 hours
Palpitations (last 24 hours)
Previous AMI 4 years ago pace maker
Ex-smoker Hypertension (HT) diabetes
Emergency Department HMO education series
2012
Examination
Unwell looking with increased work of breathing
RR 26 afeb HR Irreg 130 BP 10070
Sat 90 RA
JVP 5cm
SOA ++
Displaced apex beat no cardiac murmurs 3rd heart sound present
Normal chest expansion but stony dull percussion in the bases (RgtL) bilateral inspiratory crepitations just above the dull areas
ECG ndash what is your diagnosis
Emergency Department HMO education series
2012
Cardiac failure
Emergency Department HMO education series
2012
Case C2 - Summary
Long standing heart failure with an acute
exacerbation due to new onset rapid AF
Treatment of AF amp heart failure
Antithrombotic strategy
Then rate control
Perhaps rhythm control
See review article re AF treatment
To be published early 2013 Australian Rural Doctor
Case D
Mid 60s male
Found SOB ++ in street
Ambulance called
In ED
SOB at rest
Doesnt want help
Funny smell
Further information
Dishevelled
HR 120 reg BP 9560 Sats 94 RA
Vomiting intermittently
What will you do
Further treatment and
investigation
Further history from patient and collateral
sources
Resuscitation
IV access fluids
Bloods ndash FBC UEC CMP Blood gas
pH 71 pCO2 20 pO2 90 HCO3 10 BE -16
Further treatment and
investigation
Further history from patient and collateral
sources
Resuscitation
IV access fluids
Bloods ndash FBC UEC CMP Blood gas
pH 71 pCO2 20 pO2 90 HCO3 10 BE -16
BSL gt30
Further treatment and
investigation
Treatment
IV fluids ndash caution with Na and cerebral oedema
IV insulin
001 ndash 01 unitskghr
aim for BSL 2mmolL drop per hour
Continue until metabolic correction
Monitor and correct K+ other electrolytes
Monitor urine ketones VBGABG
Identify precipitant
Resolution
Wife arrives and is relieved to find husband
Chairman of Rotary Club
UTI developed whilst wife away for weekend
Questions
Summary
Diagnosis of the breathless patient requires you to look for clueshellip The time course of the illness
Associated symptoms
Known diseases or risk factors for disease
Treatment of illnesses supported by evidence for pneumonia asthma PE AF etc
Interpretation of radiology best done with clinical context
Thankyou
Emergency Department HMO education series
2012
What else should I ask
Travel historyhellip
Other important symptoms of respiratory
disease
Cough
Acute
Chronic
Haemoptysis (cancer TB other infections)
Chest Pain
Daytime sleepiness (obstructive sleep apnea)
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Case B
22 yo man
Brought to the ED by his partner
Sudden onset of SOB
Now present for few hours
How is your differential diagnosis affected by
the sudden onset
Emergency Department HMO education series
2013
Further history
Previously well smokes 10 cigarettesday
Left sided chest pain
Moderate
Pleuritic
Started with the SOB
Is there anything else you would like to ask
What is your differential diagnosis
Emergency Department HMO education series
2013
Emergency Department HMO education series
2012
Differential diagnosis
Pneumothorax
Arrhythmia
Pulmonary Embolism
Asthma (less likely)
Pneumonia
Anxiety
Emergency Department HMO education series
2012
Differential diagnosis
Pneumothorax
Arrhythmia
Pulmonary Embolism
Asthma (less likely)
Pneumonia
Anxiety (Imagine that being your diagnosis and you missed a pound$^ your honour)
You horrible
little doctor
Emergency Department HMO education series
2012
Examination findings
Looks unwell quite distressed with WOB
RR 26 HR 125 SR BP 8060 afebrile
Saturation 93 RA (room air)
Trachea midline
chest expansion on the left
Hyper-resonant percussion note on the left
air entry left lung
What is going on
Is this serious
What is your immediate management
Emergency Department HMO education series
2012
Describe this CXR
Emergency Department HMO education series
2012
Describe this CXR
gt or lt 2cm
Where gt 2cm then pneumothorax is gt50 and is considered large
Emergency Department HMO education series
2012
Describe this CXR
Bigger image next slide
Tethered
lung
gt2cm
Right shift of
mediastinum
Air next to
pericardium
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)
Tension
bullLarge bore cannula 2nd intercostal space mid-clavicular line
If large non-tension
bullgt2cm rim (ie gt50)
bull14-18 G cannula safe triangle (or 2ICS if contraindicated) - aspirate
bullDrain 8-14 FG is usually adequate although 28 FG may be required with
mechanical ventilation
Other considerations
bullNo improvement with drain ndash suction cardiothoracic involvement
httpthoraxbmjcomcontent58suppl_2ii39full
httpssecurecollemergencymedacukcodedocumentaspID=6194
Describe the treatment for
Pneumothorax
httpwwwbrit-thoracicorgukPortals0GuidelinesPleuralDiseaseGuidelinesPleural20Guideline202010Pleural20disease20201020pneumothoraxpdf
Emergency Department HMO education series
2012
Case B2
22 yo 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
Emergency Department HMO education series
2012
Further history amp 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
11070
Sat 97 RA
Widespread wheeze
(what causes this
sound)
Emergency Department HMO education series
2012
Investigations
If the CXR is normal (ish)hellip
Peak Flow 250min (how does this help us)
ABG on room air pH 75 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
Emergency Department HMO education series
2012
Investigations
If the CXR is normalhellip
Peak Flow 250min (how does this help us)
ABG on room air pH 75 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
Emergency Department HMO education series
2012
BBH Asthma protocol
Emergency Department HMO education series
2012
Investigations
If the CXR is normalhellip
Peak Flow 250min (how does this help us)
ABG on room air pH 75 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
Emergency Department HMO education series
2012
Investigations
If the CXR is normalhellip
Peak Flow 300min (how does this help us)
ABG on room air pH 75 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
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 httpwwwnationalasthmaorgauhealth-professionalstools-for-primary-careasthma-action-plansasthma-action-
plan-library
Asthma sticker
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 httpwwwnationalasthmaorgauhealth-professionalstools-for-primary-careasthma-action-plansasthma-action-plan-
library
Discharge checklist
Follow up referral letter to GP
Copy of letter with patient (optional)
Current asthma action plan
Triggers identified
Medications prescribed including
Relievers-short acting B agonists
Preventers-steroids
Symptom controllers-long acting B agonists (if prescribed)
Ensure medications will last until arranged review
Spacer or other delivery systems available and patient
understands use and care
Asthma handouts given (patient information fact sheet)
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 httpwwwnationalasthmaorgauhealth-professionalstools-for-primary-careasthma-action-plansasthma-action-
plan-library
Example action plan
Emergency Department HMO education series
2012
Case B3
22 yo man
Brought to the ED by his partner
Gradual onset of SOB
Now present for few hours
What else do you want to know
Emergency Department HMO education series
2012
Further history amp examination
No wheeze
Productive cough
No recent URTI
Childhood asthma (age
3-12) hay fever
No cardiac history
No risk factors for PE
RR 34 HR 110 SR BP
8965
Sat 87 RA
Dull R base with coarse
crackles
Emergency Department HMO education series
2012
Investigations
The CXR is hellip
ABG on room air
pH 730 CO2 55
O2 70 HCO3 18
What do the blood gases
show
How severe is the
problem
Emergency Department HMO education series
2012
What scoring tools for
pneumonia
SMARTCOP CURB-65 Sepsis guidelines
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
SMARTCOP
SMARTCOP
SMARTCOP
CURB 65
Various website and apps can assist you in
remembering them wwwmdcalccom
Emergency Department HMO education series
2012
Case B4 - Female in her 60rsquos
Sudden onset SOB (present now for 1 hour quite
severe) right sided pleuritic chest pain
Mild fever
Right total knee replacement 3 days ago
persistent leg swelling since yesterday
Non-smoker
No previous cardiorespiratory disease
Emergency Department HMO education series
2012
What is the differential
diagnosis
Emergency Department HMO education series
2012
What is the differential
diagnosis
Most likely
PE
Next likely
Pneumonia
Less likely
Pneumothorax
Arrhythmia
AMI
Emergency Department HMO education series
2012
On examination amp tests
Tachypnoea and some WOB
RR 24 T 376 HR 110 BP 11070
Sats 93 RA
Chest clear with normal percussion and normal breath
sounds
CXR normal
ABG pH 75 CO2 30mmHg p02 62mmHg on RA
Most likely diagnosis
What are Wells criteria
What are Wells criteria
PERC
D-Dimer
What test do you want to do
Emergency Department HMO education series
2012
What can you see
Emergency Department HMO education series
2012
Filling defect R main pulmonary trunk
Emergency Department HMO education series
2012
Emergency Department HMO education series
2012
Case C Man in 60rsquos
Woke this am very SOB and distressed ndash called
ambulance
Progressive SOB over 6 months
Chronic cough
Usually with white sputum
Now worse with no change in sputum colour
No associated fever
SOB in night ndash gets up
Ankles swollen recently
Heavy smoker (35 pack years)
Admission to local hospital 612 ago with chest pains
Emergency Department HMO education series
2012
Differential diagnosis
CCF with acute exacerbation
Chronic obstructive pulmonary disease
(COPD) with acute infective exacerbation
Anaemia
Emergency Department HMO education series
2012
Exam amp investigationshellip
Unwell RR 36 T 368 HR 90 SR BP 180102
Satrsquos 88 RA
Evidence of work of breathing and use of accessory muscles (which are these)
Pursed lip breathing
Prolonged expiration with wheeze
ABG pH 728 pCO2 60 pO2 55 HCO3 26
What do these show
Do you want a CXR
Emergency Department HMO education series
2012
Emergency Department HMO education series
2012
Diagnosis
Acute cardiac failure ndash APO
Most likely cause
Treatment
ECG ndash filed unsigned and
unseen
Emergency Department HMO education series
2012
Diagnosis
Acute cardiac failure ndash APO
Most likely cause
Treatment
Emergency Department HMO education series
2012
Diagnosis - APO
Acute cardiac failure
Treatment
Medications Nitroglycerin SL topical or IV titrated to avoid hypotension Most rapidly
venodilates reduces LV afterload and corrects myocardial ischaemia
Frusemide IV Despite universal use absolute efficacy is unclear
Ventilatory Assistance Non-invasive ventilation (NIV) reduces mortality by 40 particularly with CPAP
and reduces need to intubate
Emergency Department HMO education series
2012
Case C2 - Male in 60rsquos
Progressive SOB over 6 months worse over 24 hours
Orthopnoea Paroxysmal nocturnal dyspnoea (PND) SOA All present to a minor degree over the 6 months but worse for 24 hours
Palpitations (last 24 hours)
Previous AMI 4 years ago pace maker
Ex-smoker Hypertension (HT) diabetes
Emergency Department HMO education series
2012
Examination
Unwell looking with increased work of breathing
RR 26 afeb HR Irreg 130 BP 10070
Sat 90 RA
JVP 5cm
SOA ++
Displaced apex beat no cardiac murmurs 3rd heart sound present
Normal chest expansion but stony dull percussion in the bases (RgtL) bilateral inspiratory crepitations just above the dull areas
ECG ndash what is your diagnosis
Emergency Department HMO education series
2012
Cardiac failure
Emergency Department HMO education series
2012
Case C2 - Summary
Long standing heart failure with an acute
exacerbation due to new onset rapid AF
Treatment of AF amp heart failure
Antithrombotic strategy
Then rate control
Perhaps rhythm control
See review article re AF treatment
To be published early 2013 Australian Rural Doctor
Case D
Mid 60s male
Found SOB ++ in street
Ambulance called
In ED
SOB at rest
Doesnt want help
Funny smell
Further information
Dishevelled
HR 120 reg BP 9560 Sats 94 RA
Vomiting intermittently
What will you do
Further treatment and
investigation
Further history from patient and collateral
sources
Resuscitation
IV access fluids
Bloods ndash FBC UEC CMP Blood gas
pH 71 pCO2 20 pO2 90 HCO3 10 BE -16
Further treatment and
investigation
Further history from patient and collateral
sources
Resuscitation
IV access fluids
Bloods ndash FBC UEC CMP Blood gas
pH 71 pCO2 20 pO2 90 HCO3 10 BE -16
BSL gt30
Further treatment and
investigation
Treatment
IV fluids ndash caution with Na and cerebral oedema
IV insulin
001 ndash 01 unitskghr
aim for BSL 2mmolL drop per hour
Continue until metabolic correction
Monitor and correct K+ other electrolytes
Monitor urine ketones VBGABG
Identify precipitant
Resolution
Wife arrives and is relieved to find husband
Chairman of Rotary Club
UTI developed whilst wife away for weekend
Questions
Summary
Diagnosis of the breathless patient requires you to look for clueshellip The time course of the illness
Associated symptoms
Known diseases or risk factors for disease
Treatment of illnesses supported by evidence for pneumonia asthma PE AF etc
Interpretation of radiology best done with clinical context
Thankyou
Emergency Department HMO education series
2012
What else should I ask
Travel historyhellip
Other important symptoms of respiratory
disease
Cough
Acute
Chronic
Haemoptysis (cancer TB other infections)
Chest Pain
Daytime sleepiness (obstructive sleep apnea)
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Further history
Previously well smokes 10 cigarettesday
Left sided chest pain
Moderate
Pleuritic
Started with the SOB
Is there anything else you would like to ask
What is your differential diagnosis
Emergency Department HMO education series
2013
Emergency Department HMO education series
2012
Differential diagnosis
Pneumothorax
Arrhythmia
Pulmonary Embolism
Asthma (less likely)
Pneumonia
Anxiety
Emergency Department HMO education series
2012
Differential diagnosis
Pneumothorax
Arrhythmia
Pulmonary Embolism
Asthma (less likely)
Pneumonia
Anxiety (Imagine that being your diagnosis and you missed a pound$^ your honour)
You horrible
little doctor
Emergency Department HMO education series
2012
Examination findings
Looks unwell quite distressed with WOB
RR 26 HR 125 SR BP 8060 afebrile
Saturation 93 RA (room air)
Trachea midline
chest expansion on the left
Hyper-resonant percussion note on the left
air entry left lung
What is going on
Is this serious
What is your immediate management
Emergency Department HMO education series
2012
Describe this CXR
Emergency Department HMO education series
2012
Describe this CXR
gt or lt 2cm
Where gt 2cm then pneumothorax is gt50 and is considered large
Emergency Department HMO education series
2012
Describe this CXR
Bigger image next slide
Tethered
lung
gt2cm
Right shift of
mediastinum
Air next to
pericardium
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)
Tension
bullLarge bore cannula 2nd intercostal space mid-clavicular line
If large non-tension
bullgt2cm rim (ie gt50)
bull14-18 G cannula safe triangle (or 2ICS if contraindicated) - aspirate
bullDrain 8-14 FG is usually adequate although 28 FG may be required with
mechanical ventilation
Other considerations
bullNo improvement with drain ndash suction cardiothoracic involvement
httpthoraxbmjcomcontent58suppl_2ii39full
httpssecurecollemergencymedacukcodedocumentaspID=6194
Describe the treatment for
Pneumothorax
httpwwwbrit-thoracicorgukPortals0GuidelinesPleuralDiseaseGuidelinesPleural20Guideline202010Pleural20disease20201020pneumothoraxpdf
Emergency Department HMO education series
2012
Case B2
22 yo 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
Emergency Department HMO education series
2012
Further history amp 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
11070
Sat 97 RA
Widespread wheeze
(what causes this
sound)
Emergency Department HMO education series
2012
Investigations
If the CXR is normal (ish)hellip
Peak Flow 250min (how does this help us)
ABG on room air pH 75 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
Emergency Department HMO education series
2012
Investigations
If the CXR is normalhellip
Peak Flow 250min (how does this help us)
ABG on room air pH 75 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
Emergency Department HMO education series
2012
BBH Asthma protocol
Emergency Department HMO education series
2012
Investigations
If the CXR is normalhellip
Peak Flow 250min (how does this help us)
ABG on room air pH 75 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
Emergency Department HMO education series
2012
Investigations
If the CXR is normalhellip
Peak Flow 300min (how does this help us)
ABG on room air pH 75 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
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 httpwwwnationalasthmaorgauhealth-professionalstools-for-primary-careasthma-action-plansasthma-action-
plan-library
Asthma sticker
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 httpwwwnationalasthmaorgauhealth-professionalstools-for-primary-careasthma-action-plansasthma-action-plan-
library
Discharge checklist
Follow up referral letter to GP
Copy of letter with patient (optional)
Current asthma action plan
Triggers identified
Medications prescribed including
Relievers-short acting B agonists
Preventers-steroids
Symptom controllers-long acting B agonists (if prescribed)
Ensure medications will last until arranged review
Spacer or other delivery systems available and patient
understands use and care
Asthma handouts given (patient information fact sheet)
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 httpwwwnationalasthmaorgauhealth-professionalstools-for-primary-careasthma-action-plansasthma-action-
plan-library
Example action plan
Emergency Department HMO education series
2012
Case B3
22 yo man
Brought to the ED by his partner
Gradual onset of SOB
Now present for few hours
What else do you want to know
Emergency Department HMO education series
2012
Further history amp examination
No wheeze
Productive cough
No recent URTI
Childhood asthma (age
3-12) hay fever
No cardiac history
No risk factors for PE
RR 34 HR 110 SR BP
8965
Sat 87 RA
Dull R base with coarse
crackles
Emergency Department HMO education series
2012
Investigations
The CXR is hellip
ABG on room air
pH 730 CO2 55
O2 70 HCO3 18
What do the blood gases
show
How severe is the
problem
Emergency Department HMO education series
2012
What scoring tools for
pneumonia
SMARTCOP CURB-65 Sepsis guidelines
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
SMARTCOP
SMARTCOP
SMARTCOP
CURB 65
Various website and apps can assist you in
remembering them wwwmdcalccom
Emergency Department HMO education series
2012
Case B4 - Female in her 60rsquos
Sudden onset SOB (present now for 1 hour quite
severe) right sided pleuritic chest pain
Mild fever
Right total knee replacement 3 days ago
persistent leg swelling since yesterday
Non-smoker
No previous cardiorespiratory disease
Emergency Department HMO education series
2012
What is the differential
diagnosis
Emergency Department HMO education series
2012
What is the differential
diagnosis
Most likely
PE
Next likely
Pneumonia
Less likely
Pneumothorax
Arrhythmia
AMI
Emergency Department HMO education series
2012
On examination amp tests
Tachypnoea and some WOB
RR 24 T 376 HR 110 BP 11070
Sats 93 RA
Chest clear with normal percussion and normal breath
sounds
CXR normal
ABG pH 75 CO2 30mmHg p02 62mmHg on RA
Most likely diagnosis
What are Wells criteria
What are Wells criteria
PERC
D-Dimer
What test do you want to do
Emergency Department HMO education series
2012
What can you see
Emergency Department HMO education series
2012
Filling defect R main pulmonary trunk
Emergency Department HMO education series
2012
Emergency Department HMO education series
2012
Case C Man in 60rsquos
Woke this am very SOB and distressed ndash called
ambulance
Progressive SOB over 6 months
Chronic cough
Usually with white sputum
Now worse with no change in sputum colour
No associated fever
SOB in night ndash gets up
Ankles swollen recently
Heavy smoker (35 pack years)
Admission to local hospital 612 ago with chest pains
Emergency Department HMO education series
2012
Differential diagnosis
CCF with acute exacerbation
Chronic obstructive pulmonary disease
(COPD) with acute infective exacerbation
Anaemia
Emergency Department HMO education series
2012
Exam amp investigationshellip
Unwell RR 36 T 368 HR 90 SR BP 180102
Satrsquos 88 RA
Evidence of work of breathing and use of accessory muscles (which are these)
Pursed lip breathing
Prolonged expiration with wheeze
ABG pH 728 pCO2 60 pO2 55 HCO3 26
What do these show
Do you want a CXR
Emergency Department HMO education series
2012
Emergency Department HMO education series
2012
Diagnosis
Acute cardiac failure ndash APO
Most likely cause
Treatment
ECG ndash filed unsigned and
unseen
Emergency Department HMO education series
2012
Diagnosis
Acute cardiac failure ndash APO
Most likely cause
Treatment
Emergency Department HMO education series
2012
Diagnosis - APO
Acute cardiac failure
Treatment
Medications Nitroglycerin SL topical or IV titrated to avoid hypotension Most rapidly
venodilates reduces LV afterload and corrects myocardial ischaemia
Frusemide IV Despite universal use absolute efficacy is unclear
Ventilatory Assistance Non-invasive ventilation (NIV) reduces mortality by 40 particularly with CPAP
and reduces need to intubate
Emergency Department HMO education series
2012
Case C2 - Male in 60rsquos
Progressive SOB over 6 months worse over 24 hours
Orthopnoea Paroxysmal nocturnal dyspnoea (PND) SOA All present to a minor degree over the 6 months but worse for 24 hours
Palpitations (last 24 hours)
Previous AMI 4 years ago pace maker
Ex-smoker Hypertension (HT) diabetes
Emergency Department HMO education series
2012
Examination
Unwell looking with increased work of breathing
RR 26 afeb HR Irreg 130 BP 10070
Sat 90 RA
JVP 5cm
SOA ++
Displaced apex beat no cardiac murmurs 3rd heart sound present
Normal chest expansion but stony dull percussion in the bases (RgtL) bilateral inspiratory crepitations just above the dull areas
ECG ndash what is your diagnosis
Emergency Department HMO education series
2012
Cardiac failure
Emergency Department HMO education series
2012
Case C2 - Summary
Long standing heart failure with an acute
exacerbation due to new onset rapid AF
Treatment of AF amp heart failure
Antithrombotic strategy
Then rate control
Perhaps rhythm control
See review article re AF treatment
To be published early 2013 Australian Rural Doctor
Case D
Mid 60s male
Found SOB ++ in street
Ambulance called
In ED
SOB at rest
Doesnt want help
Funny smell
Further information
Dishevelled
HR 120 reg BP 9560 Sats 94 RA
Vomiting intermittently
What will you do
Further treatment and
investigation
Further history from patient and collateral
sources
Resuscitation
IV access fluids
Bloods ndash FBC UEC CMP Blood gas
pH 71 pCO2 20 pO2 90 HCO3 10 BE -16
Further treatment and
investigation
Further history from patient and collateral
sources
Resuscitation
IV access fluids
Bloods ndash FBC UEC CMP Blood gas
pH 71 pCO2 20 pO2 90 HCO3 10 BE -16
BSL gt30
Further treatment and
investigation
Treatment
IV fluids ndash caution with Na and cerebral oedema
IV insulin
001 ndash 01 unitskghr
aim for BSL 2mmolL drop per hour
Continue until metabolic correction
Monitor and correct K+ other electrolytes
Monitor urine ketones VBGABG
Identify precipitant
Resolution
Wife arrives and is relieved to find husband
Chairman of Rotary Club
UTI developed whilst wife away for weekend
Questions
Summary
Diagnosis of the breathless patient requires you to look for clueshellip The time course of the illness
Associated symptoms
Known diseases or risk factors for disease
Treatment of illnesses supported by evidence for pneumonia asthma PE AF etc
Interpretation of radiology best done with clinical context
Thankyou
Emergency Department HMO education series
2012
What else should I ask
Travel historyhellip
Other important symptoms of respiratory
disease
Cough
Acute
Chronic
Haemoptysis (cancer TB other infections)
Chest Pain
Daytime sleepiness (obstructive sleep apnea)
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Emergency Department HMO education series
2012
Differential diagnosis
Pneumothorax
Arrhythmia
Pulmonary Embolism
Asthma (less likely)
Pneumonia
Anxiety
Emergency Department HMO education series
2012
Differential diagnosis
Pneumothorax
Arrhythmia
Pulmonary Embolism
Asthma (less likely)
Pneumonia
Anxiety (Imagine that being your diagnosis and you missed a pound$^ your honour)
You horrible
little doctor
Emergency Department HMO education series
2012
Examination findings
Looks unwell quite distressed with WOB
RR 26 HR 125 SR BP 8060 afebrile
Saturation 93 RA (room air)
Trachea midline
chest expansion on the left
Hyper-resonant percussion note on the left
air entry left lung
What is going on
Is this serious
What is your immediate management
Emergency Department HMO education series
2012
Describe this CXR
Emergency Department HMO education series
2012
Describe this CXR
gt or lt 2cm
Where gt 2cm then pneumothorax is gt50 and is considered large
Emergency Department HMO education series
2012
Describe this CXR
Bigger image next slide
Tethered
lung
gt2cm
Right shift of
mediastinum
Air next to
pericardium
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)
Tension
bullLarge bore cannula 2nd intercostal space mid-clavicular line
If large non-tension
bullgt2cm rim (ie gt50)
bull14-18 G cannula safe triangle (or 2ICS if contraindicated) - aspirate
bullDrain 8-14 FG is usually adequate although 28 FG may be required with
mechanical ventilation
Other considerations
bullNo improvement with drain ndash suction cardiothoracic involvement
httpthoraxbmjcomcontent58suppl_2ii39full
httpssecurecollemergencymedacukcodedocumentaspID=6194
Describe the treatment for
Pneumothorax
httpwwwbrit-thoracicorgukPortals0GuidelinesPleuralDiseaseGuidelinesPleural20Guideline202010Pleural20disease20201020pneumothoraxpdf
Emergency Department HMO education series
2012
Case B2
22 yo 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
Emergency Department HMO education series
2012
Further history amp 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
11070
Sat 97 RA
Widespread wheeze
(what causes this
sound)
Emergency Department HMO education series
2012
Investigations
If the CXR is normal (ish)hellip
Peak Flow 250min (how does this help us)
ABG on room air pH 75 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
Emergency Department HMO education series
2012
Investigations
If the CXR is normalhellip
Peak Flow 250min (how does this help us)
ABG on room air pH 75 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
Emergency Department HMO education series
2012
BBH Asthma protocol
Emergency Department HMO education series
2012
Investigations
If the CXR is normalhellip
Peak Flow 250min (how does this help us)
ABG on room air pH 75 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
Emergency Department HMO education series
2012
Investigations
If the CXR is normalhellip
Peak Flow 300min (how does this help us)
ABG on room air pH 75 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
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 httpwwwnationalasthmaorgauhealth-professionalstools-for-primary-careasthma-action-plansasthma-action-
plan-library
Asthma sticker
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 httpwwwnationalasthmaorgauhealth-professionalstools-for-primary-careasthma-action-plansasthma-action-plan-
library
Discharge checklist
Follow up referral letter to GP
Copy of letter with patient (optional)
Current asthma action plan
Triggers identified
Medications prescribed including
Relievers-short acting B agonists
Preventers-steroids
Symptom controllers-long acting B agonists (if prescribed)
Ensure medications will last until arranged review
Spacer or other delivery systems available and patient
understands use and care
Asthma handouts given (patient information fact sheet)
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 httpwwwnationalasthmaorgauhealth-professionalstools-for-primary-careasthma-action-plansasthma-action-
plan-library
Example action plan
Emergency Department HMO education series
2012
Case B3
22 yo man
Brought to the ED by his partner
Gradual onset of SOB
Now present for few hours
What else do you want to know
Emergency Department HMO education series
2012
Further history amp examination
No wheeze
Productive cough
No recent URTI
Childhood asthma (age
3-12) hay fever
No cardiac history
No risk factors for PE
RR 34 HR 110 SR BP
8965
Sat 87 RA
Dull R base with coarse
crackles
Emergency Department HMO education series
2012
Investigations
The CXR is hellip
ABG on room air
pH 730 CO2 55
O2 70 HCO3 18
What do the blood gases
show
How severe is the
problem
Emergency Department HMO education series
2012
What scoring tools for
pneumonia
SMARTCOP CURB-65 Sepsis guidelines
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
SMARTCOP
SMARTCOP
SMARTCOP
CURB 65
Various website and apps can assist you in
remembering them wwwmdcalccom
Emergency Department HMO education series
2012
Case B4 - Female in her 60rsquos
Sudden onset SOB (present now for 1 hour quite
severe) right sided pleuritic chest pain
Mild fever
Right total knee replacement 3 days ago
persistent leg swelling since yesterday
Non-smoker
No previous cardiorespiratory disease
Emergency Department HMO education series
2012
What is the differential
diagnosis
Emergency Department HMO education series
2012
What is the differential
diagnosis
Most likely
PE
Next likely
Pneumonia
Less likely
Pneumothorax
Arrhythmia
AMI
Emergency Department HMO education series
2012
On examination amp tests
Tachypnoea and some WOB
RR 24 T 376 HR 110 BP 11070
Sats 93 RA
Chest clear with normal percussion and normal breath
sounds
CXR normal
ABG pH 75 CO2 30mmHg p02 62mmHg on RA
Most likely diagnosis
What are Wells criteria
What are Wells criteria
PERC
D-Dimer
What test do you want to do
Emergency Department HMO education series
2012
What can you see
Emergency Department HMO education series
2012
Filling defect R main pulmonary trunk
Emergency Department HMO education series
2012
Emergency Department HMO education series
2012
Case C Man in 60rsquos
Woke this am very SOB and distressed ndash called
ambulance
Progressive SOB over 6 months
Chronic cough
Usually with white sputum
Now worse with no change in sputum colour
No associated fever
SOB in night ndash gets up
Ankles swollen recently
Heavy smoker (35 pack years)
Admission to local hospital 612 ago with chest pains
Emergency Department HMO education series
2012
Differential diagnosis
CCF with acute exacerbation
Chronic obstructive pulmonary disease
(COPD) with acute infective exacerbation
Anaemia
Emergency Department HMO education series
2012
Exam amp investigationshellip
Unwell RR 36 T 368 HR 90 SR BP 180102
Satrsquos 88 RA
Evidence of work of breathing and use of accessory muscles (which are these)
Pursed lip breathing
Prolonged expiration with wheeze
ABG pH 728 pCO2 60 pO2 55 HCO3 26
What do these show
Do you want a CXR
Emergency Department HMO education series
2012
Emergency Department HMO education series
2012
Diagnosis
Acute cardiac failure ndash APO
Most likely cause
Treatment
ECG ndash filed unsigned and
unseen
Emergency Department HMO education series
2012
Diagnosis
Acute cardiac failure ndash APO
Most likely cause
Treatment
Emergency Department HMO education series
2012
Diagnosis - APO
Acute cardiac failure
Treatment
Medications Nitroglycerin SL topical or IV titrated to avoid hypotension Most rapidly
venodilates reduces LV afterload and corrects myocardial ischaemia
Frusemide IV Despite universal use absolute efficacy is unclear
Ventilatory Assistance Non-invasive ventilation (NIV) reduces mortality by 40 particularly with CPAP
and reduces need to intubate
Emergency Department HMO education series
2012
Case C2 - Male in 60rsquos
Progressive SOB over 6 months worse over 24 hours
Orthopnoea Paroxysmal nocturnal dyspnoea (PND) SOA All present to a minor degree over the 6 months but worse for 24 hours
Palpitations (last 24 hours)
Previous AMI 4 years ago pace maker
Ex-smoker Hypertension (HT) diabetes
Emergency Department HMO education series
2012
Examination
Unwell looking with increased work of breathing
RR 26 afeb HR Irreg 130 BP 10070
Sat 90 RA
JVP 5cm
SOA ++
Displaced apex beat no cardiac murmurs 3rd heart sound present
Normal chest expansion but stony dull percussion in the bases (RgtL) bilateral inspiratory crepitations just above the dull areas
ECG ndash what is your diagnosis
Emergency Department HMO education series
2012
Cardiac failure
Emergency Department HMO education series
2012
Case C2 - Summary
Long standing heart failure with an acute
exacerbation due to new onset rapid AF
Treatment of AF amp heart failure
Antithrombotic strategy
Then rate control
Perhaps rhythm control
See review article re AF treatment
To be published early 2013 Australian Rural Doctor
Case D
Mid 60s male
Found SOB ++ in street
Ambulance called
In ED
SOB at rest
Doesnt want help
Funny smell
Further information
Dishevelled
HR 120 reg BP 9560 Sats 94 RA
Vomiting intermittently
What will you do
Further treatment and
investigation
Further history from patient and collateral
sources
Resuscitation
IV access fluids
Bloods ndash FBC UEC CMP Blood gas
pH 71 pCO2 20 pO2 90 HCO3 10 BE -16
Further treatment and
investigation
Further history from patient and collateral
sources
Resuscitation
IV access fluids
Bloods ndash FBC UEC CMP Blood gas
pH 71 pCO2 20 pO2 90 HCO3 10 BE -16
BSL gt30
Further treatment and
investigation
Treatment
IV fluids ndash caution with Na and cerebral oedema
IV insulin
001 ndash 01 unitskghr
aim for BSL 2mmolL drop per hour
Continue until metabolic correction
Monitor and correct K+ other electrolytes
Monitor urine ketones VBGABG
Identify precipitant
Resolution
Wife arrives and is relieved to find husband
Chairman of Rotary Club
UTI developed whilst wife away for weekend
Questions
Summary
Diagnosis of the breathless patient requires you to look for clueshellip The time course of the illness
Associated symptoms
Known diseases or risk factors for disease
Treatment of illnesses supported by evidence for pneumonia asthma PE AF etc
Interpretation of radiology best done with clinical context
Thankyou
Emergency Department HMO education series
2012
What else should I ask
Travel historyhellip
Other important symptoms of respiratory
disease
Cough
Acute
Chronic
Haemoptysis (cancer TB other infections)
Chest Pain
Daytime sleepiness (obstructive sleep apnea)
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Emergency Department HMO education series
2012
Differential diagnosis
Pneumothorax
Arrhythmia
Pulmonary Embolism
Asthma (less likely)
Pneumonia
Anxiety (Imagine that being your diagnosis and you missed a pound$^ your honour)
You horrible
little doctor
Emergency Department HMO education series
2012
Examination findings
Looks unwell quite distressed with WOB
RR 26 HR 125 SR BP 8060 afebrile
Saturation 93 RA (room air)
Trachea midline
chest expansion on the left
Hyper-resonant percussion note on the left
air entry left lung
What is going on
Is this serious
What is your immediate management
Emergency Department HMO education series
2012
Describe this CXR
Emergency Department HMO education series
2012
Describe this CXR
gt or lt 2cm
Where gt 2cm then pneumothorax is gt50 and is considered large
Emergency Department HMO education series
2012
Describe this CXR
Bigger image next slide
Tethered
lung
gt2cm
Right shift of
mediastinum
Air next to
pericardium
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)
Tension
bullLarge bore cannula 2nd intercostal space mid-clavicular line
If large non-tension
bullgt2cm rim (ie gt50)
bull14-18 G cannula safe triangle (or 2ICS if contraindicated) - aspirate
bullDrain 8-14 FG is usually adequate although 28 FG may be required with
mechanical ventilation
Other considerations
bullNo improvement with drain ndash suction cardiothoracic involvement
httpthoraxbmjcomcontent58suppl_2ii39full
httpssecurecollemergencymedacukcodedocumentaspID=6194
Describe the treatment for
Pneumothorax
httpwwwbrit-thoracicorgukPortals0GuidelinesPleuralDiseaseGuidelinesPleural20Guideline202010Pleural20disease20201020pneumothoraxpdf
Emergency Department HMO education series
2012
Case B2
22 yo 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
Emergency Department HMO education series
2012
Further history amp 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
11070
Sat 97 RA
Widespread wheeze
(what causes this
sound)
Emergency Department HMO education series
2012
Investigations
If the CXR is normal (ish)hellip
Peak Flow 250min (how does this help us)
ABG on room air pH 75 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
Emergency Department HMO education series
2012
Investigations
If the CXR is normalhellip
Peak Flow 250min (how does this help us)
ABG on room air pH 75 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
Emergency Department HMO education series
2012
BBH Asthma protocol
Emergency Department HMO education series
2012
Investigations
If the CXR is normalhellip
Peak Flow 250min (how does this help us)
ABG on room air pH 75 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
Emergency Department HMO education series
2012
Investigations
If the CXR is normalhellip
Peak Flow 300min (how does this help us)
ABG on room air pH 75 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
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 httpwwwnationalasthmaorgauhealth-professionalstools-for-primary-careasthma-action-plansasthma-action-
plan-library
Asthma sticker
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 httpwwwnationalasthmaorgauhealth-professionalstools-for-primary-careasthma-action-plansasthma-action-plan-
library
Discharge checklist
Follow up referral letter to GP
Copy of letter with patient (optional)
Current asthma action plan
Triggers identified
Medications prescribed including
Relievers-short acting B agonists
Preventers-steroids
Symptom controllers-long acting B agonists (if prescribed)
Ensure medications will last until arranged review
Spacer or other delivery systems available and patient
understands use and care
Asthma handouts given (patient information fact sheet)
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 httpwwwnationalasthmaorgauhealth-professionalstools-for-primary-careasthma-action-plansasthma-action-
plan-library
Example action plan
Emergency Department HMO education series
2012
Case B3
22 yo man
Brought to the ED by his partner
Gradual onset of SOB
Now present for few hours
What else do you want to know
Emergency Department HMO education series
2012
Further history amp examination
No wheeze
Productive cough
No recent URTI
Childhood asthma (age
3-12) hay fever
No cardiac history
No risk factors for PE
RR 34 HR 110 SR BP
8965
Sat 87 RA
Dull R base with coarse
crackles
Emergency Department HMO education series
2012
Investigations
The CXR is hellip
ABG on room air
pH 730 CO2 55
O2 70 HCO3 18
What do the blood gases
show
How severe is the
problem
Emergency Department HMO education series
2012
What scoring tools for
pneumonia
SMARTCOP CURB-65 Sepsis guidelines
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
SMARTCOP
SMARTCOP
SMARTCOP
CURB 65
Various website and apps can assist you in
remembering them wwwmdcalccom
Emergency Department HMO education series
2012
Case B4 - Female in her 60rsquos
Sudden onset SOB (present now for 1 hour quite
severe) right sided pleuritic chest pain
Mild fever
Right total knee replacement 3 days ago
persistent leg swelling since yesterday
Non-smoker
No previous cardiorespiratory disease
Emergency Department HMO education series
2012
What is the differential
diagnosis
Emergency Department HMO education series
2012
What is the differential
diagnosis
Most likely
PE
Next likely
Pneumonia
Less likely
Pneumothorax
Arrhythmia
AMI
Emergency Department HMO education series
2012
On examination amp tests
Tachypnoea and some WOB
RR 24 T 376 HR 110 BP 11070
Sats 93 RA
Chest clear with normal percussion and normal breath
sounds
CXR normal
ABG pH 75 CO2 30mmHg p02 62mmHg on RA
Most likely diagnosis
What are Wells criteria
What are Wells criteria
PERC
D-Dimer
What test do you want to do
Emergency Department HMO education series
2012
What can you see
Emergency Department HMO education series
2012
Filling defect R main pulmonary trunk
Emergency Department HMO education series
2012
Emergency Department HMO education series
2012
Case C Man in 60rsquos
Woke this am very SOB and distressed ndash called
ambulance
Progressive SOB over 6 months
Chronic cough
Usually with white sputum
Now worse with no change in sputum colour
No associated fever
SOB in night ndash gets up
Ankles swollen recently
Heavy smoker (35 pack years)
Admission to local hospital 612 ago with chest pains
Emergency Department HMO education series
2012
Differential diagnosis
CCF with acute exacerbation
Chronic obstructive pulmonary disease
(COPD) with acute infective exacerbation
Anaemia
Emergency Department HMO education series
2012
Exam amp investigationshellip
Unwell RR 36 T 368 HR 90 SR BP 180102
Satrsquos 88 RA
Evidence of work of breathing and use of accessory muscles (which are these)
Pursed lip breathing
Prolonged expiration with wheeze
ABG pH 728 pCO2 60 pO2 55 HCO3 26
What do these show
Do you want a CXR
Emergency Department HMO education series
2012
Emergency Department HMO education series
2012
Diagnosis
Acute cardiac failure ndash APO
Most likely cause
Treatment
ECG ndash filed unsigned and
unseen
Emergency Department HMO education series
2012
Diagnosis
Acute cardiac failure ndash APO
Most likely cause
Treatment
Emergency Department HMO education series
2012
Diagnosis - APO
Acute cardiac failure
Treatment
Medications Nitroglycerin SL topical or IV titrated to avoid hypotension Most rapidly
venodilates reduces LV afterload and corrects myocardial ischaemia
Frusemide IV Despite universal use absolute efficacy is unclear
Ventilatory Assistance Non-invasive ventilation (NIV) reduces mortality by 40 particularly with CPAP
and reduces need to intubate
Emergency Department HMO education series
2012
Case C2 - Male in 60rsquos
Progressive SOB over 6 months worse over 24 hours
Orthopnoea Paroxysmal nocturnal dyspnoea (PND) SOA All present to a minor degree over the 6 months but worse for 24 hours
Palpitations (last 24 hours)
Previous AMI 4 years ago pace maker
Ex-smoker Hypertension (HT) diabetes
Emergency Department HMO education series
2012
Examination
Unwell looking with increased work of breathing
RR 26 afeb HR Irreg 130 BP 10070
Sat 90 RA
JVP 5cm
SOA ++
Displaced apex beat no cardiac murmurs 3rd heart sound present
Normal chest expansion but stony dull percussion in the bases (RgtL) bilateral inspiratory crepitations just above the dull areas
ECG ndash what is your diagnosis
Emergency Department HMO education series
2012
Cardiac failure
Emergency Department HMO education series
2012
Case C2 - Summary
Long standing heart failure with an acute
exacerbation due to new onset rapid AF
Treatment of AF amp heart failure
Antithrombotic strategy
Then rate control
Perhaps rhythm control
See review article re AF treatment
To be published early 2013 Australian Rural Doctor
Case D
Mid 60s male
Found SOB ++ in street
Ambulance called
In ED
SOB at rest
Doesnt want help
Funny smell
Further information
Dishevelled
HR 120 reg BP 9560 Sats 94 RA
Vomiting intermittently
What will you do
Further treatment and
investigation
Further history from patient and collateral
sources
Resuscitation
IV access fluids
Bloods ndash FBC UEC CMP Blood gas
pH 71 pCO2 20 pO2 90 HCO3 10 BE -16
Further treatment and
investigation
Further history from patient and collateral
sources
Resuscitation
IV access fluids
Bloods ndash FBC UEC CMP Blood gas
pH 71 pCO2 20 pO2 90 HCO3 10 BE -16
BSL gt30
Further treatment and
investigation
Treatment
IV fluids ndash caution with Na and cerebral oedema
IV insulin
001 ndash 01 unitskghr
aim for BSL 2mmolL drop per hour
Continue until metabolic correction
Monitor and correct K+ other electrolytes
Monitor urine ketones VBGABG
Identify precipitant
Resolution
Wife arrives and is relieved to find husband
Chairman of Rotary Club
UTI developed whilst wife away for weekend
Questions
Summary
Diagnosis of the breathless patient requires you to look for clueshellip The time course of the illness
Associated symptoms
Known diseases or risk factors for disease
Treatment of illnesses supported by evidence for pneumonia asthma PE AF etc
Interpretation of radiology best done with clinical context
Thankyou
Emergency Department HMO education series
2012
What else should I ask
Travel historyhellip
Other important symptoms of respiratory
disease
Cough
Acute
Chronic
Haemoptysis (cancer TB other infections)
Chest Pain
Daytime sleepiness (obstructive sleep apnea)
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Emergency Department HMO education series
2012
Examination findings
Looks unwell quite distressed with WOB
RR 26 HR 125 SR BP 8060 afebrile
Saturation 93 RA (room air)
Trachea midline
chest expansion on the left
Hyper-resonant percussion note on the left
air entry left lung
What is going on
Is this serious
What is your immediate management
Emergency Department HMO education series
2012
Describe this CXR
Emergency Department HMO education series
2012
Describe this CXR
gt or lt 2cm
Where gt 2cm then pneumothorax is gt50 and is considered large
Emergency Department HMO education series
2012
Describe this CXR
Bigger image next slide
Tethered
lung
gt2cm
Right shift of
mediastinum
Air next to
pericardium
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)
Tension
bullLarge bore cannula 2nd intercostal space mid-clavicular line
If large non-tension
bullgt2cm rim (ie gt50)
bull14-18 G cannula safe triangle (or 2ICS if contraindicated) - aspirate
bullDrain 8-14 FG is usually adequate although 28 FG may be required with
mechanical ventilation
Other considerations
bullNo improvement with drain ndash suction cardiothoracic involvement
httpthoraxbmjcomcontent58suppl_2ii39full
httpssecurecollemergencymedacukcodedocumentaspID=6194
Describe the treatment for
Pneumothorax
httpwwwbrit-thoracicorgukPortals0GuidelinesPleuralDiseaseGuidelinesPleural20Guideline202010Pleural20disease20201020pneumothoraxpdf
Emergency Department HMO education series
2012
Case B2
22 yo 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
Emergency Department HMO education series
2012
Further history amp 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
11070
Sat 97 RA
Widespread wheeze
(what causes this
sound)
Emergency Department HMO education series
2012
Investigations
If the CXR is normal (ish)hellip
Peak Flow 250min (how does this help us)
ABG on room air pH 75 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
Emergency Department HMO education series
2012
Investigations
If the CXR is normalhellip
Peak Flow 250min (how does this help us)
ABG on room air pH 75 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
Emergency Department HMO education series
2012
BBH Asthma protocol
Emergency Department HMO education series
2012
Investigations
If the CXR is normalhellip
Peak Flow 250min (how does this help us)
ABG on room air pH 75 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
Emergency Department HMO education series
2012
Investigations
If the CXR is normalhellip
Peak Flow 300min (how does this help us)
ABG on room air pH 75 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
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 httpwwwnationalasthmaorgauhealth-professionalstools-for-primary-careasthma-action-plansasthma-action-
plan-library
Asthma sticker
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 httpwwwnationalasthmaorgauhealth-professionalstools-for-primary-careasthma-action-plansasthma-action-plan-
library
Discharge checklist
Follow up referral letter to GP
Copy of letter with patient (optional)
Current asthma action plan
Triggers identified
Medications prescribed including
Relievers-short acting B agonists
Preventers-steroids
Symptom controllers-long acting B agonists (if prescribed)
Ensure medications will last until arranged review
Spacer or other delivery systems available and patient
understands use and care
Asthma handouts given (patient information fact sheet)
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 httpwwwnationalasthmaorgauhealth-professionalstools-for-primary-careasthma-action-plansasthma-action-
plan-library
Example action plan
Emergency Department HMO education series
2012
Case B3
22 yo man
Brought to the ED by his partner
Gradual onset of SOB
Now present for few hours
What else do you want to know
Emergency Department HMO education series
2012
Further history amp examination
No wheeze
Productive cough
No recent URTI
Childhood asthma (age
3-12) hay fever
No cardiac history
No risk factors for PE
RR 34 HR 110 SR BP
8965
Sat 87 RA
Dull R base with coarse
crackles
Emergency Department HMO education series
2012
Investigations
The CXR is hellip
ABG on room air
pH 730 CO2 55
O2 70 HCO3 18
What do the blood gases
show
How severe is the
problem
Emergency Department HMO education series
2012
What scoring tools for
pneumonia
SMARTCOP CURB-65 Sepsis guidelines
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
SMARTCOP
SMARTCOP
SMARTCOP
CURB 65
Various website and apps can assist you in
remembering them wwwmdcalccom
Emergency Department HMO education series
2012
Case B4 - Female in her 60rsquos
Sudden onset SOB (present now for 1 hour quite
severe) right sided pleuritic chest pain
Mild fever
Right total knee replacement 3 days ago
persistent leg swelling since yesterday
Non-smoker
No previous cardiorespiratory disease
Emergency Department HMO education series
2012
What is the differential
diagnosis
Emergency Department HMO education series
2012
What is the differential
diagnosis
Most likely
PE
Next likely
Pneumonia
Less likely
Pneumothorax
Arrhythmia
AMI
Emergency Department HMO education series
2012
On examination amp tests
Tachypnoea and some WOB
RR 24 T 376 HR 110 BP 11070
Sats 93 RA
Chest clear with normal percussion and normal breath
sounds
CXR normal
ABG pH 75 CO2 30mmHg p02 62mmHg on RA
Most likely diagnosis
What are Wells criteria
What are Wells criteria
PERC
D-Dimer
What test do you want to do
Emergency Department HMO education series
2012
What can you see
Emergency Department HMO education series
2012
Filling defect R main pulmonary trunk
Emergency Department HMO education series
2012
Emergency Department HMO education series
2012
Case C Man in 60rsquos
Woke this am very SOB and distressed ndash called
ambulance
Progressive SOB over 6 months
Chronic cough
Usually with white sputum
Now worse with no change in sputum colour
No associated fever
SOB in night ndash gets up
Ankles swollen recently
Heavy smoker (35 pack years)
Admission to local hospital 612 ago with chest pains
Emergency Department HMO education series
2012
Differential diagnosis
CCF with acute exacerbation
Chronic obstructive pulmonary disease
(COPD) with acute infective exacerbation
Anaemia
Emergency Department HMO education series
2012
Exam amp investigationshellip
Unwell RR 36 T 368 HR 90 SR BP 180102
Satrsquos 88 RA
Evidence of work of breathing and use of accessory muscles (which are these)
Pursed lip breathing
Prolonged expiration with wheeze
ABG pH 728 pCO2 60 pO2 55 HCO3 26
What do these show
Do you want a CXR
Emergency Department HMO education series
2012
Emergency Department HMO education series
2012
Diagnosis
Acute cardiac failure ndash APO
Most likely cause
Treatment
ECG ndash filed unsigned and
unseen
Emergency Department HMO education series
2012
Diagnosis
Acute cardiac failure ndash APO
Most likely cause
Treatment
Emergency Department HMO education series
2012
Diagnosis - APO
Acute cardiac failure
Treatment
Medications Nitroglycerin SL topical or IV titrated to avoid hypotension Most rapidly
venodilates reduces LV afterload and corrects myocardial ischaemia
Frusemide IV Despite universal use absolute efficacy is unclear
Ventilatory Assistance Non-invasive ventilation (NIV) reduces mortality by 40 particularly with CPAP
and reduces need to intubate
Emergency Department HMO education series
2012
Case C2 - Male in 60rsquos
Progressive SOB over 6 months worse over 24 hours
Orthopnoea Paroxysmal nocturnal dyspnoea (PND) SOA All present to a minor degree over the 6 months but worse for 24 hours
Palpitations (last 24 hours)
Previous AMI 4 years ago pace maker
Ex-smoker Hypertension (HT) diabetes
Emergency Department HMO education series
2012
Examination
Unwell looking with increased work of breathing
RR 26 afeb HR Irreg 130 BP 10070
Sat 90 RA
JVP 5cm
SOA ++
Displaced apex beat no cardiac murmurs 3rd heart sound present
Normal chest expansion but stony dull percussion in the bases (RgtL) bilateral inspiratory crepitations just above the dull areas
ECG ndash what is your diagnosis
Emergency Department HMO education series
2012
Cardiac failure
Emergency Department HMO education series
2012
Case C2 - Summary
Long standing heart failure with an acute
exacerbation due to new onset rapid AF
Treatment of AF amp heart failure
Antithrombotic strategy
Then rate control
Perhaps rhythm control
See review article re AF treatment
To be published early 2013 Australian Rural Doctor
Case D
Mid 60s male
Found SOB ++ in street
Ambulance called
In ED
SOB at rest
Doesnt want help
Funny smell
Further information
Dishevelled
HR 120 reg BP 9560 Sats 94 RA
Vomiting intermittently
What will you do
Further treatment and
investigation
Further history from patient and collateral
sources
Resuscitation
IV access fluids
Bloods ndash FBC UEC CMP Blood gas
pH 71 pCO2 20 pO2 90 HCO3 10 BE -16
Further treatment and
investigation
Further history from patient and collateral
sources
Resuscitation
IV access fluids
Bloods ndash FBC UEC CMP Blood gas
pH 71 pCO2 20 pO2 90 HCO3 10 BE -16
BSL gt30
Further treatment and
investigation
Treatment
IV fluids ndash caution with Na and cerebral oedema
IV insulin
001 ndash 01 unitskghr
aim for BSL 2mmolL drop per hour
Continue until metabolic correction
Monitor and correct K+ other electrolytes
Monitor urine ketones VBGABG
Identify precipitant
Resolution
Wife arrives and is relieved to find husband
Chairman of Rotary Club
UTI developed whilst wife away for weekend
Questions
Summary
Diagnosis of the breathless patient requires you to look for clueshellip The time course of the illness
Associated symptoms
Known diseases or risk factors for disease
Treatment of illnesses supported by evidence for pneumonia asthma PE AF etc
Interpretation of radiology best done with clinical context
Thankyou
Emergency Department HMO education series
2012
What else should I ask
Travel historyhellip
Other important symptoms of respiratory
disease
Cough
Acute
Chronic
Haemoptysis (cancer TB other infections)
Chest Pain
Daytime sleepiness (obstructive sleep apnea)
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
What is going on
Is this serious
What is your immediate management
Emergency Department HMO education series
2012
Describe this CXR
Emergency Department HMO education series
2012
Describe this CXR
gt or lt 2cm
Where gt 2cm then pneumothorax is gt50 and is considered large
Emergency Department HMO education series
2012
Describe this CXR
Bigger image next slide
Tethered
lung
gt2cm
Right shift of
mediastinum
Air next to
pericardium
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)
Tension
bullLarge bore cannula 2nd intercostal space mid-clavicular line
If large non-tension
bullgt2cm rim (ie gt50)
bull14-18 G cannula safe triangle (or 2ICS if contraindicated) - aspirate
bullDrain 8-14 FG is usually adequate although 28 FG may be required with
mechanical ventilation
Other considerations
bullNo improvement with drain ndash suction cardiothoracic involvement
httpthoraxbmjcomcontent58suppl_2ii39full
httpssecurecollemergencymedacukcodedocumentaspID=6194
Describe the treatment for
Pneumothorax
httpwwwbrit-thoracicorgukPortals0GuidelinesPleuralDiseaseGuidelinesPleural20Guideline202010Pleural20disease20201020pneumothoraxpdf
Emergency Department HMO education series
2012
Case B2
22 yo 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
Emergency Department HMO education series
2012
Further history amp 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
11070
Sat 97 RA
Widespread wheeze
(what causes this
sound)
Emergency Department HMO education series
2012
Investigations
If the CXR is normal (ish)hellip
Peak Flow 250min (how does this help us)
ABG on room air pH 75 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
Emergency Department HMO education series
2012
Investigations
If the CXR is normalhellip
Peak Flow 250min (how does this help us)
ABG on room air pH 75 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
Emergency Department HMO education series
2012
BBH Asthma protocol
Emergency Department HMO education series
2012
Investigations
If the CXR is normalhellip
Peak Flow 250min (how does this help us)
ABG on room air pH 75 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
Emergency Department HMO education series
2012
Investigations
If the CXR is normalhellip
Peak Flow 300min (how does this help us)
ABG on room air pH 75 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
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 httpwwwnationalasthmaorgauhealth-professionalstools-for-primary-careasthma-action-plansasthma-action-
plan-library
Asthma sticker
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 httpwwwnationalasthmaorgauhealth-professionalstools-for-primary-careasthma-action-plansasthma-action-plan-
library
Discharge checklist
Follow up referral letter to GP
Copy of letter with patient (optional)
Current asthma action plan
Triggers identified
Medications prescribed including
Relievers-short acting B agonists
Preventers-steroids
Symptom controllers-long acting B agonists (if prescribed)
Ensure medications will last until arranged review
Spacer or other delivery systems available and patient
understands use and care
Asthma handouts given (patient information fact sheet)
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 httpwwwnationalasthmaorgauhealth-professionalstools-for-primary-careasthma-action-plansasthma-action-
plan-library
Example action plan
Emergency Department HMO education series
2012
Case B3
22 yo man
Brought to the ED by his partner
Gradual onset of SOB
Now present for few hours
What else do you want to know
Emergency Department HMO education series
2012
Further history amp examination
No wheeze
Productive cough
No recent URTI
Childhood asthma (age
3-12) hay fever
No cardiac history
No risk factors for PE
RR 34 HR 110 SR BP
8965
Sat 87 RA
Dull R base with coarse
crackles
Emergency Department HMO education series
2012
Investigations
The CXR is hellip
ABG on room air
pH 730 CO2 55
O2 70 HCO3 18
What do the blood gases
show
How severe is the
problem
Emergency Department HMO education series
2012
What scoring tools for
pneumonia
SMARTCOP CURB-65 Sepsis guidelines
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
SMARTCOP
SMARTCOP
SMARTCOP
CURB 65
Various website and apps can assist you in
remembering them wwwmdcalccom
Emergency Department HMO education series
2012
Case B4 - Female in her 60rsquos
Sudden onset SOB (present now for 1 hour quite
severe) right sided pleuritic chest pain
Mild fever
Right total knee replacement 3 days ago
persistent leg swelling since yesterday
Non-smoker
No previous cardiorespiratory disease
Emergency Department HMO education series
2012
What is the differential
diagnosis
Emergency Department HMO education series
2012
What is the differential
diagnosis
Most likely
PE
Next likely
Pneumonia
Less likely
Pneumothorax
Arrhythmia
AMI
Emergency Department HMO education series
2012
On examination amp tests
Tachypnoea and some WOB
RR 24 T 376 HR 110 BP 11070
Sats 93 RA
Chest clear with normal percussion and normal breath
sounds
CXR normal
ABG pH 75 CO2 30mmHg p02 62mmHg on RA
Most likely diagnosis
What are Wells criteria
What are Wells criteria
PERC
D-Dimer
What test do you want to do
Emergency Department HMO education series
2012
What can you see
Emergency Department HMO education series
2012
Filling defect R main pulmonary trunk
Emergency Department HMO education series
2012
Emergency Department HMO education series
2012
Case C Man in 60rsquos
Woke this am very SOB and distressed ndash called
ambulance
Progressive SOB over 6 months
Chronic cough
Usually with white sputum
Now worse with no change in sputum colour
No associated fever
SOB in night ndash gets up
Ankles swollen recently
Heavy smoker (35 pack years)
Admission to local hospital 612 ago with chest pains
Emergency Department HMO education series
2012
Differential diagnosis
CCF with acute exacerbation
Chronic obstructive pulmonary disease
(COPD) with acute infective exacerbation
Anaemia
Emergency Department HMO education series
2012
Exam amp investigationshellip
Unwell RR 36 T 368 HR 90 SR BP 180102
Satrsquos 88 RA
Evidence of work of breathing and use of accessory muscles (which are these)
Pursed lip breathing
Prolonged expiration with wheeze
ABG pH 728 pCO2 60 pO2 55 HCO3 26
What do these show
Do you want a CXR
Emergency Department HMO education series
2012
Emergency Department HMO education series
2012
Diagnosis
Acute cardiac failure ndash APO
Most likely cause
Treatment
ECG ndash filed unsigned and
unseen
Emergency Department HMO education series
2012
Diagnosis
Acute cardiac failure ndash APO
Most likely cause
Treatment
Emergency Department HMO education series
2012
Diagnosis - APO
Acute cardiac failure
Treatment
Medications Nitroglycerin SL topical or IV titrated to avoid hypotension Most rapidly
venodilates reduces LV afterload and corrects myocardial ischaemia
Frusemide IV Despite universal use absolute efficacy is unclear
Ventilatory Assistance Non-invasive ventilation (NIV) reduces mortality by 40 particularly with CPAP
and reduces need to intubate
Emergency Department HMO education series
2012
Case C2 - Male in 60rsquos
Progressive SOB over 6 months worse over 24 hours
Orthopnoea Paroxysmal nocturnal dyspnoea (PND) SOA All present to a minor degree over the 6 months but worse for 24 hours
Palpitations (last 24 hours)
Previous AMI 4 years ago pace maker
Ex-smoker Hypertension (HT) diabetes
Emergency Department HMO education series
2012
Examination
Unwell looking with increased work of breathing
RR 26 afeb HR Irreg 130 BP 10070
Sat 90 RA
JVP 5cm
SOA ++
Displaced apex beat no cardiac murmurs 3rd heart sound present
Normal chest expansion but stony dull percussion in the bases (RgtL) bilateral inspiratory crepitations just above the dull areas
ECG ndash what is your diagnosis
Emergency Department HMO education series
2012
Cardiac failure
Emergency Department HMO education series
2012
Case C2 - Summary
Long standing heart failure with an acute
exacerbation due to new onset rapid AF
Treatment of AF amp heart failure
Antithrombotic strategy
Then rate control
Perhaps rhythm control
See review article re AF treatment
To be published early 2013 Australian Rural Doctor
Case D
Mid 60s male
Found SOB ++ in street
Ambulance called
In ED
SOB at rest
Doesnt want help
Funny smell
Further information
Dishevelled
HR 120 reg BP 9560 Sats 94 RA
Vomiting intermittently
What will you do
Further treatment and
investigation
Further history from patient and collateral
sources
Resuscitation
IV access fluids
Bloods ndash FBC UEC CMP Blood gas
pH 71 pCO2 20 pO2 90 HCO3 10 BE -16
Further treatment and
investigation
Further history from patient and collateral
sources
Resuscitation
IV access fluids
Bloods ndash FBC UEC CMP Blood gas
pH 71 pCO2 20 pO2 90 HCO3 10 BE -16
BSL gt30
Further treatment and
investigation
Treatment
IV fluids ndash caution with Na and cerebral oedema
IV insulin
001 ndash 01 unitskghr
aim for BSL 2mmolL drop per hour
Continue until metabolic correction
Monitor and correct K+ other electrolytes
Monitor urine ketones VBGABG
Identify precipitant
Resolution
Wife arrives and is relieved to find husband
Chairman of Rotary Club
UTI developed whilst wife away for weekend
Questions
Summary
Diagnosis of the breathless patient requires you to look for clueshellip The time course of the illness
Associated symptoms
Known diseases or risk factors for disease
Treatment of illnesses supported by evidence for pneumonia asthma PE AF etc
Interpretation of radiology best done with clinical context
Thankyou
Emergency Department HMO education series
2012
What else should I ask
Travel historyhellip
Other important symptoms of respiratory
disease
Cough
Acute
Chronic
Haemoptysis (cancer TB other infections)
Chest Pain
Daytime sleepiness (obstructive sleep apnea)
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Emergency Department HMO education series
2012
Describe this CXR
Emergency Department HMO education series
2012
Describe this CXR
gt or lt 2cm
Where gt 2cm then pneumothorax is gt50 and is considered large
Emergency Department HMO education series
2012
Describe this CXR
Bigger image next slide
Tethered
lung
gt2cm
Right shift of
mediastinum
Air next to
pericardium
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)
Tension
bullLarge bore cannula 2nd intercostal space mid-clavicular line
If large non-tension
bullgt2cm rim (ie gt50)
bull14-18 G cannula safe triangle (or 2ICS if contraindicated) - aspirate
bullDrain 8-14 FG is usually adequate although 28 FG may be required with
mechanical ventilation
Other considerations
bullNo improvement with drain ndash suction cardiothoracic involvement
httpthoraxbmjcomcontent58suppl_2ii39full
httpssecurecollemergencymedacukcodedocumentaspID=6194
Describe the treatment for
Pneumothorax
httpwwwbrit-thoracicorgukPortals0GuidelinesPleuralDiseaseGuidelinesPleural20Guideline202010Pleural20disease20201020pneumothoraxpdf
Emergency Department HMO education series
2012
Case B2
22 yo 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
Emergency Department HMO education series
2012
Further history amp 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
11070
Sat 97 RA
Widespread wheeze
(what causes this
sound)
Emergency Department HMO education series
2012
Investigations
If the CXR is normal (ish)hellip
Peak Flow 250min (how does this help us)
ABG on room air pH 75 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
Emergency Department HMO education series
2012
Investigations
If the CXR is normalhellip
Peak Flow 250min (how does this help us)
ABG on room air pH 75 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
Emergency Department HMO education series
2012
BBH Asthma protocol
Emergency Department HMO education series
2012
Investigations
If the CXR is normalhellip
Peak Flow 250min (how does this help us)
ABG on room air pH 75 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
Emergency Department HMO education series
2012
Investigations
If the CXR is normalhellip
Peak Flow 300min (how does this help us)
ABG on room air pH 75 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
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 httpwwwnationalasthmaorgauhealth-professionalstools-for-primary-careasthma-action-plansasthma-action-
plan-library
Asthma sticker
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 httpwwwnationalasthmaorgauhealth-professionalstools-for-primary-careasthma-action-plansasthma-action-plan-
library
Discharge checklist
Follow up referral letter to GP
Copy of letter with patient (optional)
Current asthma action plan
Triggers identified
Medications prescribed including
Relievers-short acting B agonists
Preventers-steroids
Symptom controllers-long acting B agonists (if prescribed)
Ensure medications will last until arranged review
Spacer or other delivery systems available and patient
understands use and care
Asthma handouts given (patient information fact sheet)
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 httpwwwnationalasthmaorgauhealth-professionalstools-for-primary-careasthma-action-plansasthma-action-
plan-library
Example action plan
Emergency Department HMO education series
2012
Case B3
22 yo man
Brought to the ED by his partner
Gradual onset of SOB
Now present for few hours
What else do you want to know
Emergency Department HMO education series
2012
Further history amp examination
No wheeze
Productive cough
No recent URTI
Childhood asthma (age
3-12) hay fever
No cardiac history
No risk factors for PE
RR 34 HR 110 SR BP
8965
Sat 87 RA
Dull R base with coarse
crackles
Emergency Department HMO education series
2012
Investigations
The CXR is hellip
ABG on room air
pH 730 CO2 55
O2 70 HCO3 18
What do the blood gases
show
How severe is the
problem
Emergency Department HMO education series
2012
What scoring tools for
pneumonia
SMARTCOP CURB-65 Sepsis guidelines
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
SMARTCOP
SMARTCOP
SMARTCOP
CURB 65
Various website and apps can assist you in
remembering them wwwmdcalccom
Emergency Department HMO education series
2012
Case B4 - Female in her 60rsquos
Sudden onset SOB (present now for 1 hour quite
severe) right sided pleuritic chest pain
Mild fever
Right total knee replacement 3 days ago
persistent leg swelling since yesterday
Non-smoker
No previous cardiorespiratory disease
Emergency Department HMO education series
2012
What is the differential
diagnosis
Emergency Department HMO education series
2012
What is the differential
diagnosis
Most likely
PE
Next likely
Pneumonia
Less likely
Pneumothorax
Arrhythmia
AMI
Emergency Department HMO education series
2012
On examination amp tests
Tachypnoea and some WOB
RR 24 T 376 HR 110 BP 11070
Sats 93 RA
Chest clear with normal percussion and normal breath
sounds
CXR normal
ABG pH 75 CO2 30mmHg p02 62mmHg on RA
Most likely diagnosis
What are Wells criteria
What are Wells criteria
PERC
D-Dimer
What test do you want to do
Emergency Department HMO education series
2012
What can you see
Emergency Department HMO education series
2012
Filling defect R main pulmonary trunk
Emergency Department HMO education series
2012
Emergency Department HMO education series
2012
Case C Man in 60rsquos
Woke this am very SOB and distressed ndash called
ambulance
Progressive SOB over 6 months
Chronic cough
Usually with white sputum
Now worse with no change in sputum colour
No associated fever
SOB in night ndash gets up
Ankles swollen recently
Heavy smoker (35 pack years)
Admission to local hospital 612 ago with chest pains
Emergency Department HMO education series
2012
Differential diagnosis
CCF with acute exacerbation
Chronic obstructive pulmonary disease
(COPD) with acute infective exacerbation
Anaemia
Emergency Department HMO education series
2012
Exam amp investigationshellip
Unwell RR 36 T 368 HR 90 SR BP 180102
Satrsquos 88 RA
Evidence of work of breathing and use of accessory muscles (which are these)
Pursed lip breathing
Prolonged expiration with wheeze
ABG pH 728 pCO2 60 pO2 55 HCO3 26
What do these show
Do you want a CXR
Emergency Department HMO education series
2012
Emergency Department HMO education series
2012
Diagnosis
Acute cardiac failure ndash APO
Most likely cause
Treatment
ECG ndash filed unsigned and
unseen
Emergency Department HMO education series
2012
Diagnosis
Acute cardiac failure ndash APO
Most likely cause
Treatment
Emergency Department HMO education series
2012
Diagnosis - APO
Acute cardiac failure
Treatment
Medications Nitroglycerin SL topical or IV titrated to avoid hypotension Most rapidly
venodilates reduces LV afterload and corrects myocardial ischaemia
Frusemide IV Despite universal use absolute efficacy is unclear
Ventilatory Assistance Non-invasive ventilation (NIV) reduces mortality by 40 particularly with CPAP
and reduces need to intubate
Emergency Department HMO education series
2012
Case C2 - Male in 60rsquos
Progressive SOB over 6 months worse over 24 hours
Orthopnoea Paroxysmal nocturnal dyspnoea (PND) SOA All present to a minor degree over the 6 months but worse for 24 hours
Palpitations (last 24 hours)
Previous AMI 4 years ago pace maker
Ex-smoker Hypertension (HT) diabetes
Emergency Department HMO education series
2012
Examination
Unwell looking with increased work of breathing
RR 26 afeb HR Irreg 130 BP 10070
Sat 90 RA
JVP 5cm
SOA ++
Displaced apex beat no cardiac murmurs 3rd heart sound present
Normal chest expansion but stony dull percussion in the bases (RgtL) bilateral inspiratory crepitations just above the dull areas
ECG ndash what is your diagnosis
Emergency Department HMO education series
2012
Cardiac failure
Emergency Department HMO education series
2012
Case C2 - Summary
Long standing heart failure with an acute
exacerbation due to new onset rapid AF
Treatment of AF amp heart failure
Antithrombotic strategy
Then rate control
Perhaps rhythm control
See review article re AF treatment
To be published early 2013 Australian Rural Doctor
Case D
Mid 60s male
Found SOB ++ in street
Ambulance called
In ED
SOB at rest
Doesnt want help
Funny smell
Further information
Dishevelled
HR 120 reg BP 9560 Sats 94 RA
Vomiting intermittently
What will you do
Further treatment and
investigation
Further history from patient and collateral
sources
Resuscitation
IV access fluids
Bloods ndash FBC UEC CMP Blood gas
pH 71 pCO2 20 pO2 90 HCO3 10 BE -16
Further treatment and
investigation
Further history from patient and collateral
sources
Resuscitation
IV access fluids
Bloods ndash FBC UEC CMP Blood gas
pH 71 pCO2 20 pO2 90 HCO3 10 BE -16
BSL gt30
Further treatment and
investigation
Treatment
IV fluids ndash caution with Na and cerebral oedema
IV insulin
001 ndash 01 unitskghr
aim for BSL 2mmolL drop per hour
Continue until metabolic correction
Monitor and correct K+ other electrolytes
Monitor urine ketones VBGABG
Identify precipitant
Resolution
Wife arrives and is relieved to find husband
Chairman of Rotary Club
UTI developed whilst wife away for weekend
Questions
Summary
Diagnosis of the breathless patient requires you to look for clueshellip The time course of the illness
Associated symptoms
Known diseases or risk factors for disease
Treatment of illnesses supported by evidence for pneumonia asthma PE AF etc
Interpretation of radiology best done with clinical context
Thankyou
Emergency Department HMO education series
2012
What else should I ask
Travel historyhellip
Other important symptoms of respiratory
disease
Cough
Acute
Chronic
Haemoptysis (cancer TB other infections)
Chest Pain
Daytime sleepiness (obstructive sleep apnea)
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Emergency Department HMO education series
2012
Describe this CXR
gt or lt 2cm
Where gt 2cm then pneumothorax is gt50 and is considered large
Emergency Department HMO education series
2012
Describe this CXR
Bigger image next slide
Tethered
lung
gt2cm
Right shift of
mediastinum
Air next to
pericardium
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)
Tension
bullLarge bore cannula 2nd intercostal space mid-clavicular line
If large non-tension
bullgt2cm rim (ie gt50)
bull14-18 G cannula safe triangle (or 2ICS if contraindicated) - aspirate
bullDrain 8-14 FG is usually adequate although 28 FG may be required with
mechanical ventilation
Other considerations
bullNo improvement with drain ndash suction cardiothoracic involvement
httpthoraxbmjcomcontent58suppl_2ii39full
httpssecurecollemergencymedacukcodedocumentaspID=6194
Describe the treatment for
Pneumothorax
httpwwwbrit-thoracicorgukPortals0GuidelinesPleuralDiseaseGuidelinesPleural20Guideline202010Pleural20disease20201020pneumothoraxpdf
Emergency Department HMO education series
2012
Case B2
22 yo 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
Emergency Department HMO education series
2012
Further history amp 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
11070
Sat 97 RA
Widespread wheeze
(what causes this
sound)
Emergency Department HMO education series
2012
Investigations
If the CXR is normal (ish)hellip
Peak Flow 250min (how does this help us)
ABG on room air pH 75 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
Emergency Department HMO education series
2012
Investigations
If the CXR is normalhellip
Peak Flow 250min (how does this help us)
ABG on room air pH 75 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
Emergency Department HMO education series
2012
BBH Asthma protocol
Emergency Department HMO education series
2012
Investigations
If the CXR is normalhellip
Peak Flow 250min (how does this help us)
ABG on room air pH 75 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
Emergency Department HMO education series
2012
Investigations
If the CXR is normalhellip
Peak Flow 300min (how does this help us)
ABG on room air pH 75 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
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 httpwwwnationalasthmaorgauhealth-professionalstools-for-primary-careasthma-action-plansasthma-action-
plan-library
Asthma sticker
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 httpwwwnationalasthmaorgauhealth-professionalstools-for-primary-careasthma-action-plansasthma-action-plan-
library
Discharge checklist
Follow up referral letter to GP
Copy of letter with patient (optional)
Current asthma action plan
Triggers identified
Medications prescribed including
Relievers-short acting B agonists
Preventers-steroids
Symptom controllers-long acting B agonists (if prescribed)
Ensure medications will last until arranged review
Spacer or other delivery systems available and patient
understands use and care
Asthma handouts given (patient information fact sheet)
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 httpwwwnationalasthmaorgauhealth-professionalstools-for-primary-careasthma-action-plansasthma-action-
plan-library
Example action plan
Emergency Department HMO education series
2012
Case B3
22 yo man
Brought to the ED by his partner
Gradual onset of SOB
Now present for few hours
What else do you want to know
Emergency Department HMO education series
2012
Further history amp examination
No wheeze
Productive cough
No recent URTI
Childhood asthma (age
3-12) hay fever
No cardiac history
No risk factors for PE
RR 34 HR 110 SR BP
8965
Sat 87 RA
Dull R base with coarse
crackles
Emergency Department HMO education series
2012
Investigations
The CXR is hellip
ABG on room air
pH 730 CO2 55
O2 70 HCO3 18
What do the blood gases
show
How severe is the
problem
Emergency Department HMO education series
2012
What scoring tools for
pneumonia
SMARTCOP CURB-65 Sepsis guidelines
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
SMARTCOP
SMARTCOP
SMARTCOP
CURB 65
Various website and apps can assist you in
remembering them wwwmdcalccom
Emergency Department HMO education series
2012
Case B4 - Female in her 60rsquos
Sudden onset SOB (present now for 1 hour quite
severe) right sided pleuritic chest pain
Mild fever
Right total knee replacement 3 days ago
persistent leg swelling since yesterday
Non-smoker
No previous cardiorespiratory disease
Emergency Department HMO education series
2012
What is the differential
diagnosis
Emergency Department HMO education series
2012
What is the differential
diagnosis
Most likely
PE
Next likely
Pneumonia
Less likely
Pneumothorax
Arrhythmia
AMI
Emergency Department HMO education series
2012
On examination amp tests
Tachypnoea and some WOB
RR 24 T 376 HR 110 BP 11070
Sats 93 RA
Chest clear with normal percussion and normal breath
sounds
CXR normal
ABG pH 75 CO2 30mmHg p02 62mmHg on RA
Most likely diagnosis
What are Wells criteria
What are Wells criteria
PERC
D-Dimer
What test do you want to do
Emergency Department HMO education series
2012
What can you see
Emergency Department HMO education series
2012
Filling defect R main pulmonary trunk
Emergency Department HMO education series
2012
Emergency Department HMO education series
2012
Case C Man in 60rsquos
Woke this am very SOB and distressed ndash called
ambulance
Progressive SOB over 6 months
Chronic cough
Usually with white sputum
Now worse with no change in sputum colour
No associated fever
SOB in night ndash gets up
Ankles swollen recently
Heavy smoker (35 pack years)
Admission to local hospital 612 ago with chest pains
Emergency Department HMO education series
2012
Differential diagnosis
CCF with acute exacerbation
Chronic obstructive pulmonary disease
(COPD) with acute infective exacerbation
Anaemia
Emergency Department HMO education series
2012
Exam amp investigationshellip
Unwell RR 36 T 368 HR 90 SR BP 180102
Satrsquos 88 RA
Evidence of work of breathing and use of accessory muscles (which are these)
Pursed lip breathing
Prolonged expiration with wheeze
ABG pH 728 pCO2 60 pO2 55 HCO3 26
What do these show
Do you want a CXR
Emergency Department HMO education series
2012
Emergency Department HMO education series
2012
Diagnosis
Acute cardiac failure ndash APO
Most likely cause
Treatment
ECG ndash filed unsigned and
unseen
Emergency Department HMO education series
2012
Diagnosis
Acute cardiac failure ndash APO
Most likely cause
Treatment
Emergency Department HMO education series
2012
Diagnosis - APO
Acute cardiac failure
Treatment
Medications Nitroglycerin SL topical or IV titrated to avoid hypotension Most rapidly
venodilates reduces LV afterload and corrects myocardial ischaemia
Frusemide IV Despite universal use absolute efficacy is unclear
Ventilatory Assistance Non-invasive ventilation (NIV) reduces mortality by 40 particularly with CPAP
and reduces need to intubate
Emergency Department HMO education series
2012
Case C2 - Male in 60rsquos
Progressive SOB over 6 months worse over 24 hours
Orthopnoea Paroxysmal nocturnal dyspnoea (PND) SOA All present to a minor degree over the 6 months but worse for 24 hours
Palpitations (last 24 hours)
Previous AMI 4 years ago pace maker
Ex-smoker Hypertension (HT) diabetes
Emergency Department HMO education series
2012
Examination
Unwell looking with increased work of breathing
RR 26 afeb HR Irreg 130 BP 10070
Sat 90 RA
JVP 5cm
SOA ++
Displaced apex beat no cardiac murmurs 3rd heart sound present
Normal chest expansion but stony dull percussion in the bases (RgtL) bilateral inspiratory crepitations just above the dull areas
ECG ndash what is your diagnosis
Emergency Department HMO education series
2012
Cardiac failure
Emergency Department HMO education series
2012
Case C2 - Summary
Long standing heart failure with an acute
exacerbation due to new onset rapid AF
Treatment of AF amp heart failure
Antithrombotic strategy
Then rate control
Perhaps rhythm control
See review article re AF treatment
To be published early 2013 Australian Rural Doctor
Case D
Mid 60s male
Found SOB ++ in street
Ambulance called
In ED
SOB at rest
Doesnt want help
Funny smell
Further information
Dishevelled
HR 120 reg BP 9560 Sats 94 RA
Vomiting intermittently
What will you do
Further treatment and
investigation
Further history from patient and collateral
sources
Resuscitation
IV access fluids
Bloods ndash FBC UEC CMP Blood gas
pH 71 pCO2 20 pO2 90 HCO3 10 BE -16
Further treatment and
investigation
Further history from patient and collateral
sources
Resuscitation
IV access fluids
Bloods ndash FBC UEC CMP Blood gas
pH 71 pCO2 20 pO2 90 HCO3 10 BE -16
BSL gt30
Further treatment and
investigation
Treatment
IV fluids ndash caution with Na and cerebral oedema
IV insulin
001 ndash 01 unitskghr
aim for BSL 2mmolL drop per hour
Continue until metabolic correction
Monitor and correct K+ other electrolytes
Monitor urine ketones VBGABG
Identify precipitant
Resolution
Wife arrives and is relieved to find husband
Chairman of Rotary Club
UTI developed whilst wife away for weekend
Questions
Summary
Diagnosis of the breathless patient requires you to look for clueshellip The time course of the illness
Associated symptoms
Known diseases or risk factors for disease
Treatment of illnesses supported by evidence for pneumonia asthma PE AF etc
Interpretation of radiology best done with clinical context
Thankyou
Emergency Department HMO education series
2012
What else should I ask
Travel historyhellip
Other important symptoms of respiratory
disease
Cough
Acute
Chronic
Haemoptysis (cancer TB other infections)
Chest Pain
Daytime sleepiness (obstructive sleep apnea)
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Emergency Department HMO education series
2012
Describe this CXR
Bigger image next slide
Tethered
lung
gt2cm
Right shift of
mediastinum
Air next to
pericardium
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)
Tension
bullLarge bore cannula 2nd intercostal space mid-clavicular line
If large non-tension
bullgt2cm rim (ie gt50)
bull14-18 G cannula safe triangle (or 2ICS if contraindicated) - aspirate
bullDrain 8-14 FG is usually adequate although 28 FG may be required with
mechanical ventilation
Other considerations
bullNo improvement with drain ndash suction cardiothoracic involvement
httpthoraxbmjcomcontent58suppl_2ii39full
httpssecurecollemergencymedacukcodedocumentaspID=6194
Describe the treatment for
Pneumothorax
httpwwwbrit-thoracicorgukPortals0GuidelinesPleuralDiseaseGuidelinesPleural20Guideline202010Pleural20disease20201020pneumothoraxpdf
Emergency Department HMO education series
2012
Case B2
22 yo 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
Emergency Department HMO education series
2012
Further history amp 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
11070
Sat 97 RA
Widespread wheeze
(what causes this
sound)
Emergency Department HMO education series
2012
Investigations
If the CXR is normal (ish)hellip
Peak Flow 250min (how does this help us)
ABG on room air pH 75 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
Emergency Department HMO education series
2012
Investigations
If the CXR is normalhellip
Peak Flow 250min (how does this help us)
ABG on room air pH 75 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
Emergency Department HMO education series
2012
BBH Asthma protocol
Emergency Department HMO education series
2012
Investigations
If the CXR is normalhellip
Peak Flow 250min (how does this help us)
ABG on room air pH 75 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
Emergency Department HMO education series
2012
Investigations
If the CXR is normalhellip
Peak Flow 300min (how does this help us)
ABG on room air pH 75 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
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 httpwwwnationalasthmaorgauhealth-professionalstools-for-primary-careasthma-action-plansasthma-action-
plan-library
Asthma sticker
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 httpwwwnationalasthmaorgauhealth-professionalstools-for-primary-careasthma-action-plansasthma-action-plan-
library
Discharge checklist
Follow up referral letter to GP
Copy of letter with patient (optional)
Current asthma action plan
Triggers identified
Medications prescribed including
Relievers-short acting B agonists
Preventers-steroids
Symptom controllers-long acting B agonists (if prescribed)
Ensure medications will last until arranged review
Spacer or other delivery systems available and patient
understands use and care
Asthma handouts given (patient information fact sheet)
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 httpwwwnationalasthmaorgauhealth-professionalstools-for-primary-careasthma-action-plansasthma-action-
plan-library
Example action plan
Emergency Department HMO education series
2012
Case B3
22 yo man
Brought to the ED by his partner
Gradual onset of SOB
Now present for few hours
What else do you want to know
Emergency Department HMO education series
2012
Further history amp examination
No wheeze
Productive cough
No recent URTI
Childhood asthma (age
3-12) hay fever
No cardiac history
No risk factors for PE
RR 34 HR 110 SR BP
8965
Sat 87 RA
Dull R base with coarse
crackles
Emergency Department HMO education series
2012
Investigations
The CXR is hellip
ABG on room air
pH 730 CO2 55
O2 70 HCO3 18
What do the blood gases
show
How severe is the
problem
Emergency Department HMO education series
2012
What scoring tools for
pneumonia
SMARTCOP CURB-65 Sepsis guidelines
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
SMARTCOP
SMARTCOP
SMARTCOP
CURB 65
Various website and apps can assist you in
remembering them wwwmdcalccom
Emergency Department HMO education series
2012
Case B4 - Female in her 60rsquos
Sudden onset SOB (present now for 1 hour quite
severe) right sided pleuritic chest pain
Mild fever
Right total knee replacement 3 days ago
persistent leg swelling since yesterday
Non-smoker
No previous cardiorespiratory disease
Emergency Department HMO education series
2012
What is the differential
diagnosis
Emergency Department HMO education series
2012
What is the differential
diagnosis
Most likely
PE
Next likely
Pneumonia
Less likely
Pneumothorax
Arrhythmia
AMI
Emergency Department HMO education series
2012
On examination amp tests
Tachypnoea and some WOB
RR 24 T 376 HR 110 BP 11070
Sats 93 RA
Chest clear with normal percussion and normal breath
sounds
CXR normal
ABG pH 75 CO2 30mmHg p02 62mmHg on RA
Most likely diagnosis
What are Wells criteria
What are Wells criteria
PERC
D-Dimer
What test do you want to do
Emergency Department HMO education series
2012
What can you see
Emergency Department HMO education series
2012
Filling defect R main pulmonary trunk
Emergency Department HMO education series
2012
Emergency Department HMO education series
2012
Case C Man in 60rsquos
Woke this am very SOB and distressed ndash called
ambulance
Progressive SOB over 6 months
Chronic cough
Usually with white sputum
Now worse with no change in sputum colour
No associated fever
SOB in night ndash gets up
Ankles swollen recently
Heavy smoker (35 pack years)
Admission to local hospital 612 ago with chest pains
Emergency Department HMO education series
2012
Differential diagnosis
CCF with acute exacerbation
Chronic obstructive pulmonary disease
(COPD) with acute infective exacerbation
Anaemia
Emergency Department HMO education series
2012
Exam amp investigationshellip
Unwell RR 36 T 368 HR 90 SR BP 180102
Satrsquos 88 RA
Evidence of work of breathing and use of accessory muscles (which are these)
Pursed lip breathing
Prolonged expiration with wheeze
ABG pH 728 pCO2 60 pO2 55 HCO3 26
What do these show
Do you want a CXR
Emergency Department HMO education series
2012
Emergency Department HMO education series
2012
Diagnosis
Acute cardiac failure ndash APO
Most likely cause
Treatment
ECG ndash filed unsigned and
unseen
Emergency Department HMO education series
2012
Diagnosis
Acute cardiac failure ndash APO
Most likely cause
Treatment
Emergency Department HMO education series
2012
Diagnosis - APO
Acute cardiac failure
Treatment
Medications Nitroglycerin SL topical or IV titrated to avoid hypotension Most rapidly
venodilates reduces LV afterload and corrects myocardial ischaemia
Frusemide IV Despite universal use absolute efficacy is unclear
Ventilatory Assistance Non-invasive ventilation (NIV) reduces mortality by 40 particularly with CPAP
and reduces need to intubate
Emergency Department HMO education series
2012
Case C2 - Male in 60rsquos
Progressive SOB over 6 months worse over 24 hours
Orthopnoea Paroxysmal nocturnal dyspnoea (PND) SOA All present to a minor degree over the 6 months but worse for 24 hours
Palpitations (last 24 hours)
Previous AMI 4 years ago pace maker
Ex-smoker Hypertension (HT) diabetes
Emergency Department HMO education series
2012
Examination
Unwell looking with increased work of breathing
RR 26 afeb HR Irreg 130 BP 10070
Sat 90 RA
JVP 5cm
SOA ++
Displaced apex beat no cardiac murmurs 3rd heart sound present
Normal chest expansion but stony dull percussion in the bases (RgtL) bilateral inspiratory crepitations just above the dull areas
ECG ndash what is your diagnosis
Emergency Department HMO education series
2012
Cardiac failure
Emergency Department HMO education series
2012
Case C2 - Summary
Long standing heart failure with an acute
exacerbation due to new onset rapid AF
Treatment of AF amp heart failure
Antithrombotic strategy
Then rate control
Perhaps rhythm control
See review article re AF treatment
To be published early 2013 Australian Rural Doctor
Case D
Mid 60s male
Found SOB ++ in street
Ambulance called
In ED
SOB at rest
Doesnt want help
Funny smell
Further information
Dishevelled
HR 120 reg BP 9560 Sats 94 RA
Vomiting intermittently
What will you do
Further treatment and
investigation
Further history from patient and collateral
sources
Resuscitation
IV access fluids
Bloods ndash FBC UEC CMP Blood gas
pH 71 pCO2 20 pO2 90 HCO3 10 BE -16
Further treatment and
investigation
Further history from patient and collateral
sources
Resuscitation
IV access fluids
Bloods ndash FBC UEC CMP Blood gas
pH 71 pCO2 20 pO2 90 HCO3 10 BE -16
BSL gt30
Further treatment and
investigation
Treatment
IV fluids ndash caution with Na and cerebral oedema
IV insulin
001 ndash 01 unitskghr
aim for BSL 2mmolL drop per hour
Continue until metabolic correction
Monitor and correct K+ other electrolytes
Monitor urine ketones VBGABG
Identify precipitant
Resolution
Wife arrives and is relieved to find husband
Chairman of Rotary Club
UTI developed whilst wife away for weekend
Questions
Summary
Diagnosis of the breathless patient requires you to look for clueshellip The time course of the illness
Associated symptoms
Known diseases or risk factors for disease
Treatment of illnesses supported by evidence for pneumonia asthma PE AF etc
Interpretation of radiology best done with clinical context
Thankyou
Emergency Department HMO education series
2012
What else should I ask
Travel historyhellip
Other important symptoms of respiratory
disease
Cough
Acute
Chronic
Haemoptysis (cancer TB other infections)
Chest Pain
Daytime sleepiness (obstructive sleep apnea)
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Tethered
lung
gt2cm
Right shift of
mediastinum
Air next to
pericardium
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)
Tension
bullLarge bore cannula 2nd intercostal space mid-clavicular line
If large non-tension
bullgt2cm rim (ie gt50)
bull14-18 G cannula safe triangle (or 2ICS if contraindicated) - aspirate
bullDrain 8-14 FG is usually adequate although 28 FG may be required with
mechanical ventilation
Other considerations
bullNo improvement with drain ndash suction cardiothoracic involvement
httpthoraxbmjcomcontent58suppl_2ii39full
httpssecurecollemergencymedacukcodedocumentaspID=6194
Describe the treatment for
Pneumothorax
httpwwwbrit-thoracicorgukPortals0GuidelinesPleuralDiseaseGuidelinesPleural20Guideline202010Pleural20disease20201020pneumothoraxpdf
Emergency Department HMO education series
2012
Case B2
22 yo 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
Emergency Department HMO education series
2012
Further history amp 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
11070
Sat 97 RA
Widespread wheeze
(what causes this
sound)
Emergency Department HMO education series
2012
Investigations
If the CXR is normal (ish)hellip
Peak Flow 250min (how does this help us)
ABG on room air pH 75 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
Emergency Department HMO education series
2012
Investigations
If the CXR is normalhellip
Peak Flow 250min (how does this help us)
ABG on room air pH 75 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
Emergency Department HMO education series
2012
BBH Asthma protocol
Emergency Department HMO education series
2012
Investigations
If the CXR is normalhellip
Peak Flow 250min (how does this help us)
ABG on room air pH 75 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
Emergency Department HMO education series
2012
Investigations
If the CXR is normalhellip
Peak Flow 300min (how does this help us)
ABG on room air pH 75 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
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 httpwwwnationalasthmaorgauhealth-professionalstools-for-primary-careasthma-action-plansasthma-action-
plan-library
Asthma sticker
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 httpwwwnationalasthmaorgauhealth-professionalstools-for-primary-careasthma-action-plansasthma-action-plan-
library
Discharge checklist
Follow up referral letter to GP
Copy of letter with patient (optional)
Current asthma action plan
Triggers identified
Medications prescribed including
Relievers-short acting B agonists
Preventers-steroids
Symptom controllers-long acting B agonists (if prescribed)
Ensure medications will last until arranged review
Spacer or other delivery systems available and patient
understands use and care
Asthma handouts given (patient information fact sheet)
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 httpwwwnationalasthmaorgauhealth-professionalstools-for-primary-careasthma-action-plansasthma-action-
plan-library
Example action plan
Emergency Department HMO education series
2012
Case B3
22 yo man
Brought to the ED by his partner
Gradual onset of SOB
Now present for few hours
What else do you want to know
Emergency Department HMO education series
2012
Further history amp examination
No wheeze
Productive cough
No recent URTI
Childhood asthma (age
3-12) hay fever
No cardiac history
No risk factors for PE
RR 34 HR 110 SR BP
8965
Sat 87 RA
Dull R base with coarse
crackles
Emergency Department HMO education series
2012
Investigations
The CXR is hellip
ABG on room air
pH 730 CO2 55
O2 70 HCO3 18
What do the blood gases
show
How severe is the
problem
Emergency Department HMO education series
2012
What scoring tools for
pneumonia
SMARTCOP CURB-65 Sepsis guidelines
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
SMARTCOP
SMARTCOP
SMARTCOP
CURB 65
Various website and apps can assist you in
remembering them wwwmdcalccom
Emergency Department HMO education series
2012
Case B4 - Female in her 60rsquos
Sudden onset SOB (present now for 1 hour quite
severe) right sided pleuritic chest pain
Mild fever
Right total knee replacement 3 days ago
persistent leg swelling since yesterday
Non-smoker
No previous cardiorespiratory disease
Emergency Department HMO education series
2012
What is the differential
diagnosis
Emergency Department HMO education series
2012
What is the differential
diagnosis
Most likely
PE
Next likely
Pneumonia
Less likely
Pneumothorax
Arrhythmia
AMI
Emergency Department HMO education series
2012
On examination amp tests
Tachypnoea and some WOB
RR 24 T 376 HR 110 BP 11070
Sats 93 RA
Chest clear with normal percussion and normal breath
sounds
CXR normal
ABG pH 75 CO2 30mmHg p02 62mmHg on RA
Most likely diagnosis
What are Wells criteria
What are Wells criteria
PERC
D-Dimer
What test do you want to do
Emergency Department HMO education series
2012
What can you see
Emergency Department HMO education series
2012
Filling defect R main pulmonary trunk
Emergency Department HMO education series
2012
Emergency Department HMO education series
2012
Case C Man in 60rsquos
Woke this am very SOB and distressed ndash called
ambulance
Progressive SOB over 6 months
Chronic cough
Usually with white sputum
Now worse with no change in sputum colour
No associated fever
SOB in night ndash gets up
Ankles swollen recently
Heavy smoker (35 pack years)
Admission to local hospital 612 ago with chest pains
Emergency Department HMO education series
2012
Differential diagnosis
CCF with acute exacerbation
Chronic obstructive pulmonary disease
(COPD) with acute infective exacerbation
Anaemia
Emergency Department HMO education series
2012
Exam amp investigationshellip
Unwell RR 36 T 368 HR 90 SR BP 180102
Satrsquos 88 RA
Evidence of work of breathing and use of accessory muscles (which are these)
Pursed lip breathing
Prolonged expiration with wheeze
ABG pH 728 pCO2 60 pO2 55 HCO3 26
What do these show
Do you want a CXR
Emergency Department HMO education series
2012
Emergency Department HMO education series
2012
Diagnosis
Acute cardiac failure ndash APO
Most likely cause
Treatment
ECG ndash filed unsigned and
unseen
Emergency Department HMO education series
2012
Diagnosis
Acute cardiac failure ndash APO
Most likely cause
Treatment
Emergency Department HMO education series
2012
Diagnosis - APO
Acute cardiac failure
Treatment
Medications Nitroglycerin SL topical or IV titrated to avoid hypotension Most rapidly
venodilates reduces LV afterload and corrects myocardial ischaemia
Frusemide IV Despite universal use absolute efficacy is unclear
Ventilatory Assistance Non-invasive ventilation (NIV) reduces mortality by 40 particularly with CPAP
and reduces need to intubate
Emergency Department HMO education series
2012
Case C2 - Male in 60rsquos
Progressive SOB over 6 months worse over 24 hours
Orthopnoea Paroxysmal nocturnal dyspnoea (PND) SOA All present to a minor degree over the 6 months but worse for 24 hours
Palpitations (last 24 hours)
Previous AMI 4 years ago pace maker
Ex-smoker Hypertension (HT) diabetes
Emergency Department HMO education series
2012
Examination
Unwell looking with increased work of breathing
RR 26 afeb HR Irreg 130 BP 10070
Sat 90 RA
JVP 5cm
SOA ++
Displaced apex beat no cardiac murmurs 3rd heart sound present
Normal chest expansion but stony dull percussion in the bases (RgtL) bilateral inspiratory crepitations just above the dull areas
ECG ndash what is your diagnosis
Emergency Department HMO education series
2012
Cardiac failure
Emergency Department HMO education series
2012
Case C2 - Summary
Long standing heart failure with an acute
exacerbation due to new onset rapid AF
Treatment of AF amp heart failure
Antithrombotic strategy
Then rate control
Perhaps rhythm control
See review article re AF treatment
To be published early 2013 Australian Rural Doctor
Case D
Mid 60s male
Found SOB ++ in street
Ambulance called
In ED
SOB at rest
Doesnt want help
Funny smell
Further information
Dishevelled
HR 120 reg BP 9560 Sats 94 RA
Vomiting intermittently
What will you do
Further treatment and
investigation
Further history from patient and collateral
sources
Resuscitation
IV access fluids
Bloods ndash FBC UEC CMP Blood gas
pH 71 pCO2 20 pO2 90 HCO3 10 BE -16
Further treatment and
investigation
Further history from patient and collateral
sources
Resuscitation
IV access fluids
Bloods ndash FBC UEC CMP Blood gas
pH 71 pCO2 20 pO2 90 HCO3 10 BE -16
BSL gt30
Further treatment and
investigation
Treatment
IV fluids ndash caution with Na and cerebral oedema
IV insulin
001 ndash 01 unitskghr
aim for BSL 2mmolL drop per hour
Continue until metabolic correction
Monitor and correct K+ other electrolytes
Monitor urine ketones VBGABG
Identify precipitant
Resolution
Wife arrives and is relieved to find husband
Chairman of Rotary Club
UTI developed whilst wife away for weekend
Questions
Summary
Diagnosis of the breathless patient requires you to look for clueshellip The time course of the illness
Associated symptoms
Known diseases or risk factors for disease
Treatment of illnesses supported by evidence for pneumonia asthma PE AF etc
Interpretation of radiology best done with clinical context
Thankyou
Emergency Department HMO education series
2012
What else should I ask
Travel historyhellip
Other important symptoms of respiratory
disease
Cough
Acute
Chronic
Haemoptysis (cancer TB other infections)
Chest Pain
Daytime sleepiness (obstructive sleep apnea)
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
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)
Tension
bullLarge bore cannula 2nd intercostal space mid-clavicular line
If large non-tension
bullgt2cm rim (ie gt50)
bull14-18 G cannula safe triangle (or 2ICS if contraindicated) - aspirate
bullDrain 8-14 FG is usually adequate although 28 FG may be required with
mechanical ventilation
Other considerations
bullNo improvement with drain ndash suction cardiothoracic involvement
httpthoraxbmjcomcontent58suppl_2ii39full
httpssecurecollemergencymedacukcodedocumentaspID=6194
Describe the treatment for
Pneumothorax
httpwwwbrit-thoracicorgukPortals0GuidelinesPleuralDiseaseGuidelinesPleural20Guideline202010Pleural20disease20201020pneumothoraxpdf
Emergency Department HMO education series
2012
Case B2
22 yo 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
Emergency Department HMO education series
2012
Further history amp 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
11070
Sat 97 RA
Widespread wheeze
(what causes this
sound)
Emergency Department HMO education series
2012
Investigations
If the CXR is normal (ish)hellip
Peak Flow 250min (how does this help us)
ABG on room air pH 75 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
Emergency Department HMO education series
2012
Investigations
If the CXR is normalhellip
Peak Flow 250min (how does this help us)
ABG on room air pH 75 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
Emergency Department HMO education series
2012
BBH Asthma protocol
Emergency Department HMO education series
2012
Investigations
If the CXR is normalhellip
Peak Flow 250min (how does this help us)
ABG on room air pH 75 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
Emergency Department HMO education series
2012
Investigations
If the CXR is normalhellip
Peak Flow 300min (how does this help us)
ABG on room air pH 75 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
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 httpwwwnationalasthmaorgauhealth-professionalstools-for-primary-careasthma-action-plansasthma-action-
plan-library
Asthma sticker
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 httpwwwnationalasthmaorgauhealth-professionalstools-for-primary-careasthma-action-plansasthma-action-plan-
library
Discharge checklist
Follow up referral letter to GP
Copy of letter with patient (optional)
Current asthma action plan
Triggers identified
Medications prescribed including
Relievers-short acting B agonists
Preventers-steroids
Symptom controllers-long acting B agonists (if prescribed)
Ensure medications will last until arranged review
Spacer or other delivery systems available and patient
understands use and care
Asthma handouts given (patient information fact sheet)
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 httpwwwnationalasthmaorgauhealth-professionalstools-for-primary-careasthma-action-plansasthma-action-
plan-library
Example action plan
Emergency Department HMO education series
2012
Case B3
22 yo man
Brought to the ED by his partner
Gradual onset of SOB
Now present for few hours
What else do you want to know
Emergency Department HMO education series
2012
Further history amp examination
No wheeze
Productive cough
No recent URTI
Childhood asthma (age
3-12) hay fever
No cardiac history
No risk factors for PE
RR 34 HR 110 SR BP
8965
Sat 87 RA
Dull R base with coarse
crackles
Emergency Department HMO education series
2012
Investigations
The CXR is hellip
ABG on room air
pH 730 CO2 55
O2 70 HCO3 18
What do the blood gases
show
How severe is the
problem
Emergency Department HMO education series
2012
What scoring tools for
pneumonia
SMARTCOP CURB-65 Sepsis guidelines
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
SMARTCOP
SMARTCOP
SMARTCOP
CURB 65
Various website and apps can assist you in
remembering them wwwmdcalccom
Emergency Department HMO education series
2012
Case B4 - Female in her 60rsquos
Sudden onset SOB (present now for 1 hour quite
severe) right sided pleuritic chest pain
Mild fever
Right total knee replacement 3 days ago
persistent leg swelling since yesterday
Non-smoker
No previous cardiorespiratory disease
Emergency Department HMO education series
2012
What is the differential
diagnosis
Emergency Department HMO education series
2012
What is the differential
diagnosis
Most likely
PE
Next likely
Pneumonia
Less likely
Pneumothorax
Arrhythmia
AMI
Emergency Department HMO education series
2012
On examination amp tests
Tachypnoea and some WOB
RR 24 T 376 HR 110 BP 11070
Sats 93 RA
Chest clear with normal percussion and normal breath
sounds
CXR normal
ABG pH 75 CO2 30mmHg p02 62mmHg on RA
Most likely diagnosis
What are Wells criteria
What are Wells criteria
PERC
D-Dimer
What test do you want to do
Emergency Department HMO education series
2012
What can you see
Emergency Department HMO education series
2012
Filling defect R main pulmonary trunk
Emergency Department HMO education series
2012
Emergency Department HMO education series
2012
Case C Man in 60rsquos
Woke this am very SOB and distressed ndash called
ambulance
Progressive SOB over 6 months
Chronic cough
Usually with white sputum
Now worse with no change in sputum colour
No associated fever
SOB in night ndash gets up
Ankles swollen recently
Heavy smoker (35 pack years)
Admission to local hospital 612 ago with chest pains
Emergency Department HMO education series
2012
Differential diagnosis
CCF with acute exacerbation
Chronic obstructive pulmonary disease
(COPD) with acute infective exacerbation
Anaemia
Emergency Department HMO education series
2012
Exam amp investigationshellip
Unwell RR 36 T 368 HR 90 SR BP 180102
Satrsquos 88 RA
Evidence of work of breathing and use of accessory muscles (which are these)
Pursed lip breathing
Prolonged expiration with wheeze
ABG pH 728 pCO2 60 pO2 55 HCO3 26
What do these show
Do you want a CXR
Emergency Department HMO education series
2012
Emergency Department HMO education series
2012
Diagnosis
Acute cardiac failure ndash APO
Most likely cause
Treatment
ECG ndash filed unsigned and
unseen
Emergency Department HMO education series
2012
Diagnosis
Acute cardiac failure ndash APO
Most likely cause
Treatment
Emergency Department HMO education series
2012
Diagnosis - APO
Acute cardiac failure
Treatment
Medications Nitroglycerin SL topical or IV titrated to avoid hypotension Most rapidly
venodilates reduces LV afterload and corrects myocardial ischaemia
Frusemide IV Despite universal use absolute efficacy is unclear
Ventilatory Assistance Non-invasive ventilation (NIV) reduces mortality by 40 particularly with CPAP
and reduces need to intubate
Emergency Department HMO education series
2012
Case C2 - Male in 60rsquos
Progressive SOB over 6 months worse over 24 hours
Orthopnoea Paroxysmal nocturnal dyspnoea (PND) SOA All present to a minor degree over the 6 months but worse for 24 hours
Palpitations (last 24 hours)
Previous AMI 4 years ago pace maker
Ex-smoker Hypertension (HT) diabetes
Emergency Department HMO education series
2012
Examination
Unwell looking with increased work of breathing
RR 26 afeb HR Irreg 130 BP 10070
Sat 90 RA
JVP 5cm
SOA ++
Displaced apex beat no cardiac murmurs 3rd heart sound present
Normal chest expansion but stony dull percussion in the bases (RgtL) bilateral inspiratory crepitations just above the dull areas
ECG ndash what is your diagnosis
Emergency Department HMO education series
2012
Cardiac failure
Emergency Department HMO education series
2012
Case C2 - Summary
Long standing heart failure with an acute
exacerbation due to new onset rapid AF
Treatment of AF amp heart failure
Antithrombotic strategy
Then rate control
Perhaps rhythm control
See review article re AF treatment
To be published early 2013 Australian Rural Doctor
Case D
Mid 60s male
Found SOB ++ in street
Ambulance called
In ED
SOB at rest
Doesnt want help
Funny smell
Further information
Dishevelled
HR 120 reg BP 9560 Sats 94 RA
Vomiting intermittently
What will you do
Further treatment and
investigation
Further history from patient and collateral
sources
Resuscitation
IV access fluids
Bloods ndash FBC UEC CMP Blood gas
pH 71 pCO2 20 pO2 90 HCO3 10 BE -16
Further treatment and
investigation
Further history from patient and collateral
sources
Resuscitation
IV access fluids
Bloods ndash FBC UEC CMP Blood gas
pH 71 pCO2 20 pO2 90 HCO3 10 BE -16
BSL gt30
Further treatment and
investigation
Treatment
IV fluids ndash caution with Na and cerebral oedema
IV insulin
001 ndash 01 unitskghr
aim for BSL 2mmolL drop per hour
Continue until metabolic correction
Monitor and correct K+ other electrolytes
Monitor urine ketones VBGABG
Identify precipitant
Resolution
Wife arrives and is relieved to find husband
Chairman of Rotary Club
UTI developed whilst wife away for weekend
Questions
Summary
Diagnosis of the breathless patient requires you to look for clueshellip The time course of the illness
Associated symptoms
Known diseases or risk factors for disease
Treatment of illnesses supported by evidence for pneumonia asthma PE AF etc
Interpretation of radiology best done with clinical context
Thankyou
Emergency Department HMO education series
2012
What else should I ask
Travel historyhellip
Other important symptoms of respiratory
disease
Cough
Acute
Chronic
Haemoptysis (cancer TB other infections)
Chest Pain
Daytime sleepiness (obstructive sleep apnea)
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Tension
bullLarge bore cannula 2nd intercostal space mid-clavicular line
If large non-tension
bullgt2cm rim (ie gt50)
bull14-18 G cannula safe triangle (or 2ICS if contraindicated) - aspirate
bullDrain 8-14 FG is usually adequate although 28 FG may be required with
mechanical ventilation
Other considerations
bullNo improvement with drain ndash suction cardiothoracic involvement
httpthoraxbmjcomcontent58suppl_2ii39full
httpssecurecollemergencymedacukcodedocumentaspID=6194
Describe the treatment for
Pneumothorax
httpwwwbrit-thoracicorgukPortals0GuidelinesPleuralDiseaseGuidelinesPleural20Guideline202010Pleural20disease20201020pneumothoraxpdf
Emergency Department HMO education series
2012
Case B2
22 yo 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
Emergency Department HMO education series
2012
Further history amp 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
11070
Sat 97 RA
Widespread wheeze
(what causes this
sound)
Emergency Department HMO education series
2012
Investigations
If the CXR is normal (ish)hellip
Peak Flow 250min (how does this help us)
ABG on room air pH 75 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
Emergency Department HMO education series
2012
Investigations
If the CXR is normalhellip
Peak Flow 250min (how does this help us)
ABG on room air pH 75 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
Emergency Department HMO education series
2012
BBH Asthma protocol
Emergency Department HMO education series
2012
Investigations
If the CXR is normalhellip
Peak Flow 250min (how does this help us)
ABG on room air pH 75 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
Emergency Department HMO education series
2012
Investigations
If the CXR is normalhellip
Peak Flow 300min (how does this help us)
ABG on room air pH 75 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
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 httpwwwnationalasthmaorgauhealth-professionalstools-for-primary-careasthma-action-plansasthma-action-
plan-library
Asthma sticker
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 httpwwwnationalasthmaorgauhealth-professionalstools-for-primary-careasthma-action-plansasthma-action-plan-
library
Discharge checklist
Follow up referral letter to GP
Copy of letter with patient (optional)
Current asthma action plan
Triggers identified
Medications prescribed including
Relievers-short acting B agonists
Preventers-steroids
Symptom controllers-long acting B agonists (if prescribed)
Ensure medications will last until arranged review
Spacer or other delivery systems available and patient
understands use and care
Asthma handouts given (patient information fact sheet)
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 httpwwwnationalasthmaorgauhealth-professionalstools-for-primary-careasthma-action-plansasthma-action-
plan-library
Example action plan
Emergency Department HMO education series
2012
Case B3
22 yo man
Brought to the ED by his partner
Gradual onset of SOB
Now present for few hours
What else do you want to know
Emergency Department HMO education series
2012
Further history amp examination
No wheeze
Productive cough
No recent URTI
Childhood asthma (age
3-12) hay fever
No cardiac history
No risk factors for PE
RR 34 HR 110 SR BP
8965
Sat 87 RA
Dull R base with coarse
crackles
Emergency Department HMO education series
2012
Investigations
The CXR is hellip
ABG on room air
pH 730 CO2 55
O2 70 HCO3 18
What do the blood gases
show
How severe is the
problem
Emergency Department HMO education series
2012
What scoring tools for
pneumonia
SMARTCOP CURB-65 Sepsis guidelines
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
SMARTCOP
SMARTCOP
SMARTCOP
CURB 65
Various website and apps can assist you in
remembering them wwwmdcalccom
Emergency Department HMO education series
2012
Case B4 - Female in her 60rsquos
Sudden onset SOB (present now for 1 hour quite
severe) right sided pleuritic chest pain
Mild fever
Right total knee replacement 3 days ago
persistent leg swelling since yesterday
Non-smoker
No previous cardiorespiratory disease
Emergency Department HMO education series
2012
What is the differential
diagnosis
Emergency Department HMO education series
2012
What is the differential
diagnosis
Most likely
PE
Next likely
Pneumonia
Less likely
Pneumothorax
Arrhythmia
AMI
Emergency Department HMO education series
2012
On examination amp tests
Tachypnoea and some WOB
RR 24 T 376 HR 110 BP 11070
Sats 93 RA
Chest clear with normal percussion and normal breath
sounds
CXR normal
ABG pH 75 CO2 30mmHg p02 62mmHg on RA
Most likely diagnosis
What are Wells criteria
What are Wells criteria
PERC
D-Dimer
What test do you want to do
Emergency Department HMO education series
2012
What can you see
Emergency Department HMO education series
2012
Filling defect R main pulmonary trunk
Emergency Department HMO education series
2012
Emergency Department HMO education series
2012
Case C Man in 60rsquos
Woke this am very SOB and distressed ndash called
ambulance
Progressive SOB over 6 months
Chronic cough
Usually with white sputum
Now worse with no change in sputum colour
No associated fever
SOB in night ndash gets up
Ankles swollen recently
Heavy smoker (35 pack years)
Admission to local hospital 612 ago with chest pains
Emergency Department HMO education series
2012
Differential diagnosis
CCF with acute exacerbation
Chronic obstructive pulmonary disease
(COPD) with acute infective exacerbation
Anaemia
Emergency Department HMO education series
2012
Exam amp investigationshellip
Unwell RR 36 T 368 HR 90 SR BP 180102
Satrsquos 88 RA
Evidence of work of breathing and use of accessory muscles (which are these)
Pursed lip breathing
Prolonged expiration with wheeze
ABG pH 728 pCO2 60 pO2 55 HCO3 26
What do these show
Do you want a CXR
Emergency Department HMO education series
2012
Emergency Department HMO education series
2012
Diagnosis
Acute cardiac failure ndash APO
Most likely cause
Treatment
ECG ndash filed unsigned and
unseen
Emergency Department HMO education series
2012
Diagnosis
Acute cardiac failure ndash APO
Most likely cause
Treatment
Emergency Department HMO education series
2012
Diagnosis - APO
Acute cardiac failure
Treatment
Medications Nitroglycerin SL topical or IV titrated to avoid hypotension Most rapidly
venodilates reduces LV afterload and corrects myocardial ischaemia
Frusemide IV Despite universal use absolute efficacy is unclear
Ventilatory Assistance Non-invasive ventilation (NIV) reduces mortality by 40 particularly with CPAP
and reduces need to intubate
Emergency Department HMO education series
2012
Case C2 - Male in 60rsquos
Progressive SOB over 6 months worse over 24 hours
Orthopnoea Paroxysmal nocturnal dyspnoea (PND) SOA All present to a minor degree over the 6 months but worse for 24 hours
Palpitations (last 24 hours)
Previous AMI 4 years ago pace maker
Ex-smoker Hypertension (HT) diabetes
Emergency Department HMO education series
2012
Examination
Unwell looking with increased work of breathing
RR 26 afeb HR Irreg 130 BP 10070
Sat 90 RA
JVP 5cm
SOA ++
Displaced apex beat no cardiac murmurs 3rd heart sound present
Normal chest expansion but stony dull percussion in the bases (RgtL) bilateral inspiratory crepitations just above the dull areas
ECG ndash what is your diagnosis
Emergency Department HMO education series
2012
Cardiac failure
Emergency Department HMO education series
2012
Case C2 - Summary
Long standing heart failure with an acute
exacerbation due to new onset rapid AF
Treatment of AF amp heart failure
Antithrombotic strategy
Then rate control
Perhaps rhythm control
See review article re AF treatment
To be published early 2013 Australian Rural Doctor
Case D
Mid 60s male
Found SOB ++ in street
Ambulance called
In ED
SOB at rest
Doesnt want help
Funny smell
Further information
Dishevelled
HR 120 reg BP 9560 Sats 94 RA
Vomiting intermittently
What will you do
Further treatment and
investigation
Further history from patient and collateral
sources
Resuscitation
IV access fluids
Bloods ndash FBC UEC CMP Blood gas
pH 71 pCO2 20 pO2 90 HCO3 10 BE -16
Further treatment and
investigation
Further history from patient and collateral
sources
Resuscitation
IV access fluids
Bloods ndash FBC UEC CMP Blood gas
pH 71 pCO2 20 pO2 90 HCO3 10 BE -16
BSL gt30
Further treatment and
investigation
Treatment
IV fluids ndash caution with Na and cerebral oedema
IV insulin
001 ndash 01 unitskghr
aim for BSL 2mmolL drop per hour
Continue until metabolic correction
Monitor and correct K+ other electrolytes
Monitor urine ketones VBGABG
Identify precipitant
Resolution
Wife arrives and is relieved to find husband
Chairman of Rotary Club
UTI developed whilst wife away for weekend
Questions
Summary
Diagnosis of the breathless patient requires you to look for clueshellip The time course of the illness
Associated symptoms
Known diseases or risk factors for disease
Treatment of illnesses supported by evidence for pneumonia asthma PE AF etc
Interpretation of radiology best done with clinical context
Thankyou
Emergency Department HMO education series
2012
What else should I ask
Travel historyhellip
Other important symptoms of respiratory
disease
Cough
Acute
Chronic
Haemoptysis (cancer TB other infections)
Chest Pain
Daytime sleepiness (obstructive sleep apnea)
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
httpwwwbrit-thoracicorgukPortals0GuidelinesPleuralDiseaseGuidelinesPleural20Guideline202010Pleural20disease20201020pneumothoraxpdf
Emergency Department HMO education series
2012
Case B2
22 yo 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
Emergency Department HMO education series
2012
Further history amp 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
11070
Sat 97 RA
Widespread wheeze
(what causes this
sound)
Emergency Department HMO education series
2012
Investigations
If the CXR is normal (ish)hellip
Peak Flow 250min (how does this help us)
ABG on room air pH 75 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
Emergency Department HMO education series
2012
Investigations
If the CXR is normalhellip
Peak Flow 250min (how does this help us)
ABG on room air pH 75 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
Emergency Department HMO education series
2012
BBH Asthma protocol
Emergency Department HMO education series
2012
Investigations
If the CXR is normalhellip
Peak Flow 250min (how does this help us)
ABG on room air pH 75 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
Emergency Department HMO education series
2012
Investigations
If the CXR is normalhellip
Peak Flow 300min (how does this help us)
ABG on room air pH 75 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
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 httpwwwnationalasthmaorgauhealth-professionalstools-for-primary-careasthma-action-plansasthma-action-
plan-library
Asthma sticker
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 httpwwwnationalasthmaorgauhealth-professionalstools-for-primary-careasthma-action-plansasthma-action-plan-
library
Discharge checklist
Follow up referral letter to GP
Copy of letter with patient (optional)
Current asthma action plan
Triggers identified
Medications prescribed including
Relievers-short acting B agonists
Preventers-steroids
Symptom controllers-long acting B agonists (if prescribed)
Ensure medications will last until arranged review
Spacer or other delivery systems available and patient
understands use and care
Asthma handouts given (patient information fact sheet)
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 httpwwwnationalasthmaorgauhealth-professionalstools-for-primary-careasthma-action-plansasthma-action-
plan-library
Example action plan
Emergency Department HMO education series
2012
Case B3
22 yo man
Brought to the ED by his partner
Gradual onset of SOB
Now present for few hours
What else do you want to know
Emergency Department HMO education series
2012
Further history amp examination
No wheeze
Productive cough
No recent URTI
Childhood asthma (age
3-12) hay fever
No cardiac history
No risk factors for PE
RR 34 HR 110 SR BP
8965
Sat 87 RA
Dull R base with coarse
crackles
Emergency Department HMO education series
2012
Investigations
The CXR is hellip
ABG on room air
pH 730 CO2 55
O2 70 HCO3 18
What do the blood gases
show
How severe is the
problem
Emergency Department HMO education series
2012
What scoring tools for
pneumonia
SMARTCOP CURB-65 Sepsis guidelines
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
SMARTCOP
SMARTCOP
SMARTCOP
CURB 65
Various website and apps can assist you in
remembering them wwwmdcalccom
Emergency Department HMO education series
2012
Case B4 - Female in her 60rsquos
Sudden onset SOB (present now for 1 hour quite
severe) right sided pleuritic chest pain
Mild fever
Right total knee replacement 3 days ago
persistent leg swelling since yesterday
Non-smoker
No previous cardiorespiratory disease
Emergency Department HMO education series
2012
What is the differential
diagnosis
Emergency Department HMO education series
2012
What is the differential
diagnosis
Most likely
PE
Next likely
Pneumonia
Less likely
Pneumothorax
Arrhythmia
AMI
Emergency Department HMO education series
2012
On examination amp tests
Tachypnoea and some WOB
RR 24 T 376 HR 110 BP 11070
Sats 93 RA
Chest clear with normal percussion and normal breath
sounds
CXR normal
ABG pH 75 CO2 30mmHg p02 62mmHg on RA
Most likely diagnosis
What are Wells criteria
What are Wells criteria
PERC
D-Dimer
What test do you want to do
Emergency Department HMO education series
2012
What can you see
Emergency Department HMO education series
2012
Filling defect R main pulmonary trunk
Emergency Department HMO education series
2012
Emergency Department HMO education series
2012
Case C Man in 60rsquos
Woke this am very SOB and distressed ndash called
ambulance
Progressive SOB over 6 months
Chronic cough
Usually with white sputum
Now worse with no change in sputum colour
No associated fever
SOB in night ndash gets up
Ankles swollen recently
Heavy smoker (35 pack years)
Admission to local hospital 612 ago with chest pains
Emergency Department HMO education series
2012
Differential diagnosis
CCF with acute exacerbation
Chronic obstructive pulmonary disease
(COPD) with acute infective exacerbation
Anaemia
Emergency Department HMO education series
2012
Exam amp investigationshellip
Unwell RR 36 T 368 HR 90 SR BP 180102
Satrsquos 88 RA
Evidence of work of breathing and use of accessory muscles (which are these)
Pursed lip breathing
Prolonged expiration with wheeze
ABG pH 728 pCO2 60 pO2 55 HCO3 26
What do these show
Do you want a CXR
Emergency Department HMO education series
2012
Emergency Department HMO education series
2012
Diagnosis
Acute cardiac failure ndash APO
Most likely cause
Treatment
ECG ndash filed unsigned and
unseen
Emergency Department HMO education series
2012
Diagnosis
Acute cardiac failure ndash APO
Most likely cause
Treatment
Emergency Department HMO education series
2012
Diagnosis - APO
Acute cardiac failure
Treatment
Medications Nitroglycerin SL topical or IV titrated to avoid hypotension Most rapidly
venodilates reduces LV afterload and corrects myocardial ischaemia
Frusemide IV Despite universal use absolute efficacy is unclear
Ventilatory Assistance Non-invasive ventilation (NIV) reduces mortality by 40 particularly with CPAP
and reduces need to intubate
Emergency Department HMO education series
2012
Case C2 - Male in 60rsquos
Progressive SOB over 6 months worse over 24 hours
Orthopnoea Paroxysmal nocturnal dyspnoea (PND) SOA All present to a minor degree over the 6 months but worse for 24 hours
Palpitations (last 24 hours)
Previous AMI 4 years ago pace maker
Ex-smoker Hypertension (HT) diabetes
Emergency Department HMO education series
2012
Examination
Unwell looking with increased work of breathing
RR 26 afeb HR Irreg 130 BP 10070
Sat 90 RA
JVP 5cm
SOA ++
Displaced apex beat no cardiac murmurs 3rd heart sound present
Normal chest expansion but stony dull percussion in the bases (RgtL) bilateral inspiratory crepitations just above the dull areas
ECG ndash what is your diagnosis
Emergency Department HMO education series
2012
Cardiac failure
Emergency Department HMO education series
2012
Case C2 - Summary
Long standing heart failure with an acute
exacerbation due to new onset rapid AF
Treatment of AF amp heart failure
Antithrombotic strategy
Then rate control
Perhaps rhythm control
See review article re AF treatment
To be published early 2013 Australian Rural Doctor
Case D
Mid 60s male
Found SOB ++ in street
Ambulance called
In ED
SOB at rest
Doesnt want help
Funny smell
Further information
Dishevelled
HR 120 reg BP 9560 Sats 94 RA
Vomiting intermittently
What will you do
Further treatment and
investigation
Further history from patient and collateral
sources
Resuscitation
IV access fluids
Bloods ndash FBC UEC CMP Blood gas
pH 71 pCO2 20 pO2 90 HCO3 10 BE -16
Further treatment and
investigation
Further history from patient and collateral
sources
Resuscitation
IV access fluids
Bloods ndash FBC UEC CMP Blood gas
pH 71 pCO2 20 pO2 90 HCO3 10 BE -16
BSL gt30
Further treatment and
investigation
Treatment
IV fluids ndash caution with Na and cerebral oedema
IV insulin
001 ndash 01 unitskghr
aim for BSL 2mmolL drop per hour
Continue until metabolic correction
Monitor and correct K+ other electrolytes
Monitor urine ketones VBGABG
Identify precipitant
Resolution
Wife arrives and is relieved to find husband
Chairman of Rotary Club
UTI developed whilst wife away for weekend
Questions
Summary
Diagnosis of the breathless patient requires you to look for clueshellip The time course of the illness
Associated symptoms
Known diseases or risk factors for disease
Treatment of illnesses supported by evidence for pneumonia asthma PE AF etc
Interpretation of radiology best done with clinical context
Thankyou
Emergency Department HMO education series
2012
What else should I ask
Travel historyhellip
Other important symptoms of respiratory
disease
Cough
Acute
Chronic
Haemoptysis (cancer TB other infections)
Chest Pain
Daytime sleepiness (obstructive sleep apnea)
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Emergency Department HMO education series
2012
Case B2
22 yo 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
Emergency Department HMO education series
2012
Further history amp 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
11070
Sat 97 RA
Widespread wheeze
(what causes this
sound)
Emergency Department HMO education series
2012
Investigations
If the CXR is normal (ish)hellip
Peak Flow 250min (how does this help us)
ABG on room air pH 75 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
Emergency Department HMO education series
2012
Investigations
If the CXR is normalhellip
Peak Flow 250min (how does this help us)
ABG on room air pH 75 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
Emergency Department HMO education series
2012
BBH Asthma protocol
Emergency Department HMO education series
2012
Investigations
If the CXR is normalhellip
Peak Flow 250min (how does this help us)
ABG on room air pH 75 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
Emergency Department HMO education series
2012
Investigations
If the CXR is normalhellip
Peak Flow 300min (how does this help us)
ABG on room air pH 75 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
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 httpwwwnationalasthmaorgauhealth-professionalstools-for-primary-careasthma-action-plansasthma-action-
plan-library
Asthma sticker
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 httpwwwnationalasthmaorgauhealth-professionalstools-for-primary-careasthma-action-plansasthma-action-plan-
library
Discharge checklist
Follow up referral letter to GP
Copy of letter with patient (optional)
Current asthma action plan
Triggers identified
Medications prescribed including
Relievers-short acting B agonists
Preventers-steroids
Symptom controllers-long acting B agonists (if prescribed)
Ensure medications will last until arranged review
Spacer or other delivery systems available and patient
understands use and care
Asthma handouts given (patient information fact sheet)
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 httpwwwnationalasthmaorgauhealth-professionalstools-for-primary-careasthma-action-plansasthma-action-
plan-library
Example action plan
Emergency Department HMO education series
2012
Case B3
22 yo man
Brought to the ED by his partner
Gradual onset of SOB
Now present for few hours
What else do you want to know
Emergency Department HMO education series
2012
Further history amp examination
No wheeze
Productive cough
No recent URTI
Childhood asthma (age
3-12) hay fever
No cardiac history
No risk factors for PE
RR 34 HR 110 SR BP
8965
Sat 87 RA
Dull R base with coarse
crackles
Emergency Department HMO education series
2012
Investigations
The CXR is hellip
ABG on room air
pH 730 CO2 55
O2 70 HCO3 18
What do the blood gases
show
How severe is the
problem
Emergency Department HMO education series
2012
What scoring tools for
pneumonia
SMARTCOP CURB-65 Sepsis guidelines
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
SMARTCOP
SMARTCOP
SMARTCOP
CURB 65
Various website and apps can assist you in
remembering them wwwmdcalccom
Emergency Department HMO education series
2012
Case B4 - Female in her 60rsquos
Sudden onset SOB (present now for 1 hour quite
severe) right sided pleuritic chest pain
Mild fever
Right total knee replacement 3 days ago
persistent leg swelling since yesterday
Non-smoker
No previous cardiorespiratory disease
Emergency Department HMO education series
2012
What is the differential
diagnosis
Emergency Department HMO education series
2012
What is the differential
diagnosis
Most likely
PE
Next likely
Pneumonia
Less likely
Pneumothorax
Arrhythmia
AMI
Emergency Department HMO education series
2012
On examination amp tests
Tachypnoea and some WOB
RR 24 T 376 HR 110 BP 11070
Sats 93 RA
Chest clear with normal percussion and normal breath
sounds
CXR normal
ABG pH 75 CO2 30mmHg p02 62mmHg on RA
Most likely diagnosis
What are Wells criteria
What are Wells criteria
PERC
D-Dimer
What test do you want to do
Emergency Department HMO education series
2012
What can you see
Emergency Department HMO education series
2012
Filling defect R main pulmonary trunk
Emergency Department HMO education series
2012
Emergency Department HMO education series
2012
Case C Man in 60rsquos
Woke this am very SOB and distressed ndash called
ambulance
Progressive SOB over 6 months
Chronic cough
Usually with white sputum
Now worse with no change in sputum colour
No associated fever
SOB in night ndash gets up
Ankles swollen recently
Heavy smoker (35 pack years)
Admission to local hospital 612 ago with chest pains
Emergency Department HMO education series
2012
Differential diagnosis
CCF with acute exacerbation
Chronic obstructive pulmonary disease
(COPD) with acute infective exacerbation
Anaemia
Emergency Department HMO education series
2012
Exam amp investigationshellip
Unwell RR 36 T 368 HR 90 SR BP 180102
Satrsquos 88 RA
Evidence of work of breathing and use of accessory muscles (which are these)
Pursed lip breathing
Prolonged expiration with wheeze
ABG pH 728 pCO2 60 pO2 55 HCO3 26
What do these show
Do you want a CXR
Emergency Department HMO education series
2012
Emergency Department HMO education series
2012
Diagnosis
Acute cardiac failure ndash APO
Most likely cause
Treatment
ECG ndash filed unsigned and
unseen
Emergency Department HMO education series
2012
Diagnosis
Acute cardiac failure ndash APO
Most likely cause
Treatment
Emergency Department HMO education series
2012
Diagnosis - APO
Acute cardiac failure
Treatment
Medications Nitroglycerin SL topical or IV titrated to avoid hypotension Most rapidly
venodilates reduces LV afterload and corrects myocardial ischaemia
Frusemide IV Despite universal use absolute efficacy is unclear
Ventilatory Assistance Non-invasive ventilation (NIV) reduces mortality by 40 particularly with CPAP
and reduces need to intubate
Emergency Department HMO education series
2012
Case C2 - Male in 60rsquos
Progressive SOB over 6 months worse over 24 hours
Orthopnoea Paroxysmal nocturnal dyspnoea (PND) SOA All present to a minor degree over the 6 months but worse for 24 hours
Palpitations (last 24 hours)
Previous AMI 4 years ago pace maker
Ex-smoker Hypertension (HT) diabetes
Emergency Department HMO education series
2012
Examination
Unwell looking with increased work of breathing
RR 26 afeb HR Irreg 130 BP 10070
Sat 90 RA
JVP 5cm
SOA ++
Displaced apex beat no cardiac murmurs 3rd heart sound present
Normal chest expansion but stony dull percussion in the bases (RgtL) bilateral inspiratory crepitations just above the dull areas
ECG ndash what is your diagnosis
Emergency Department HMO education series
2012
Cardiac failure
Emergency Department HMO education series
2012
Case C2 - Summary
Long standing heart failure with an acute
exacerbation due to new onset rapid AF
Treatment of AF amp heart failure
Antithrombotic strategy
Then rate control
Perhaps rhythm control
See review article re AF treatment
To be published early 2013 Australian Rural Doctor
Case D
Mid 60s male
Found SOB ++ in street
Ambulance called
In ED
SOB at rest
Doesnt want help
Funny smell
Further information
Dishevelled
HR 120 reg BP 9560 Sats 94 RA
Vomiting intermittently
What will you do
Further treatment and
investigation
Further history from patient and collateral
sources
Resuscitation
IV access fluids
Bloods ndash FBC UEC CMP Blood gas
pH 71 pCO2 20 pO2 90 HCO3 10 BE -16
Further treatment and
investigation
Further history from patient and collateral
sources
Resuscitation
IV access fluids
Bloods ndash FBC UEC CMP Blood gas
pH 71 pCO2 20 pO2 90 HCO3 10 BE -16
BSL gt30
Further treatment and
investigation
Treatment
IV fluids ndash caution with Na and cerebral oedema
IV insulin
001 ndash 01 unitskghr
aim for BSL 2mmolL drop per hour
Continue until metabolic correction
Monitor and correct K+ other electrolytes
Monitor urine ketones VBGABG
Identify precipitant
Resolution
Wife arrives and is relieved to find husband
Chairman of Rotary Club
UTI developed whilst wife away for weekend
Questions
Summary
Diagnosis of the breathless patient requires you to look for clueshellip The time course of the illness
Associated symptoms
Known diseases or risk factors for disease
Treatment of illnesses supported by evidence for pneumonia asthma PE AF etc
Interpretation of radiology best done with clinical context
Thankyou
Emergency Department HMO education series
2012
What else should I ask
Travel historyhellip
Other important symptoms of respiratory
disease
Cough
Acute
Chronic
Haemoptysis (cancer TB other infections)
Chest Pain
Daytime sleepiness (obstructive sleep apnea)
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Emergency Department HMO education series
2012
Further history amp 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
11070
Sat 97 RA
Widespread wheeze
(what causes this
sound)
Emergency Department HMO education series
2012
Investigations
If the CXR is normal (ish)hellip
Peak Flow 250min (how does this help us)
ABG on room air pH 75 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
Emergency Department HMO education series
2012
Investigations
If the CXR is normalhellip
Peak Flow 250min (how does this help us)
ABG on room air pH 75 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
Emergency Department HMO education series
2012
BBH Asthma protocol
Emergency Department HMO education series
2012
Investigations
If the CXR is normalhellip
Peak Flow 250min (how does this help us)
ABG on room air pH 75 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
Emergency Department HMO education series
2012
Investigations
If the CXR is normalhellip
Peak Flow 300min (how does this help us)
ABG on room air pH 75 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
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 httpwwwnationalasthmaorgauhealth-professionalstools-for-primary-careasthma-action-plansasthma-action-
plan-library
Asthma sticker
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 httpwwwnationalasthmaorgauhealth-professionalstools-for-primary-careasthma-action-plansasthma-action-plan-
library
Discharge checklist
Follow up referral letter to GP
Copy of letter with patient (optional)
Current asthma action plan
Triggers identified
Medications prescribed including
Relievers-short acting B agonists
Preventers-steroids
Symptom controllers-long acting B agonists (if prescribed)
Ensure medications will last until arranged review
Spacer or other delivery systems available and patient
understands use and care
Asthma handouts given (patient information fact sheet)
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 httpwwwnationalasthmaorgauhealth-professionalstools-for-primary-careasthma-action-plansasthma-action-
plan-library
Example action plan
Emergency Department HMO education series
2012
Case B3
22 yo man
Brought to the ED by his partner
Gradual onset of SOB
Now present for few hours
What else do you want to know
Emergency Department HMO education series
2012
Further history amp examination
No wheeze
Productive cough
No recent URTI
Childhood asthma (age
3-12) hay fever
No cardiac history
No risk factors for PE
RR 34 HR 110 SR BP
8965
Sat 87 RA
Dull R base with coarse
crackles
Emergency Department HMO education series
2012
Investigations
The CXR is hellip
ABG on room air
pH 730 CO2 55
O2 70 HCO3 18
What do the blood gases
show
How severe is the
problem
Emergency Department HMO education series
2012
What scoring tools for
pneumonia
SMARTCOP CURB-65 Sepsis guidelines
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
SMARTCOP
SMARTCOP
SMARTCOP
CURB 65
Various website and apps can assist you in
remembering them wwwmdcalccom
Emergency Department HMO education series
2012
Case B4 - Female in her 60rsquos
Sudden onset SOB (present now for 1 hour quite
severe) right sided pleuritic chest pain
Mild fever
Right total knee replacement 3 days ago
persistent leg swelling since yesterday
Non-smoker
No previous cardiorespiratory disease
Emergency Department HMO education series
2012
What is the differential
diagnosis
Emergency Department HMO education series
2012
What is the differential
diagnosis
Most likely
PE
Next likely
Pneumonia
Less likely
Pneumothorax
Arrhythmia
AMI
Emergency Department HMO education series
2012
On examination amp tests
Tachypnoea and some WOB
RR 24 T 376 HR 110 BP 11070
Sats 93 RA
Chest clear with normal percussion and normal breath
sounds
CXR normal
ABG pH 75 CO2 30mmHg p02 62mmHg on RA
Most likely diagnosis
What are Wells criteria
What are Wells criteria
PERC
D-Dimer
What test do you want to do
Emergency Department HMO education series
2012
What can you see
Emergency Department HMO education series
2012
Filling defect R main pulmonary trunk
Emergency Department HMO education series
2012
Emergency Department HMO education series
2012
Case C Man in 60rsquos
Woke this am very SOB and distressed ndash called
ambulance
Progressive SOB over 6 months
Chronic cough
Usually with white sputum
Now worse with no change in sputum colour
No associated fever
SOB in night ndash gets up
Ankles swollen recently
Heavy smoker (35 pack years)
Admission to local hospital 612 ago with chest pains
Emergency Department HMO education series
2012
Differential diagnosis
CCF with acute exacerbation
Chronic obstructive pulmonary disease
(COPD) with acute infective exacerbation
Anaemia
Emergency Department HMO education series
2012
Exam amp investigationshellip
Unwell RR 36 T 368 HR 90 SR BP 180102
Satrsquos 88 RA
Evidence of work of breathing and use of accessory muscles (which are these)
Pursed lip breathing
Prolonged expiration with wheeze
ABG pH 728 pCO2 60 pO2 55 HCO3 26
What do these show
Do you want a CXR
Emergency Department HMO education series
2012
Emergency Department HMO education series
2012
Diagnosis
Acute cardiac failure ndash APO
Most likely cause
Treatment
ECG ndash filed unsigned and
unseen
Emergency Department HMO education series
2012
Diagnosis
Acute cardiac failure ndash APO
Most likely cause
Treatment
Emergency Department HMO education series
2012
Diagnosis - APO
Acute cardiac failure
Treatment
Medications Nitroglycerin SL topical or IV titrated to avoid hypotension Most rapidly
venodilates reduces LV afterload and corrects myocardial ischaemia
Frusemide IV Despite universal use absolute efficacy is unclear
Ventilatory Assistance Non-invasive ventilation (NIV) reduces mortality by 40 particularly with CPAP
and reduces need to intubate
Emergency Department HMO education series
2012
Case C2 - Male in 60rsquos
Progressive SOB over 6 months worse over 24 hours
Orthopnoea Paroxysmal nocturnal dyspnoea (PND) SOA All present to a minor degree over the 6 months but worse for 24 hours
Palpitations (last 24 hours)
Previous AMI 4 years ago pace maker
Ex-smoker Hypertension (HT) diabetes
Emergency Department HMO education series
2012
Examination
Unwell looking with increased work of breathing
RR 26 afeb HR Irreg 130 BP 10070
Sat 90 RA
JVP 5cm
SOA ++
Displaced apex beat no cardiac murmurs 3rd heart sound present
Normal chest expansion but stony dull percussion in the bases (RgtL) bilateral inspiratory crepitations just above the dull areas
ECG ndash what is your diagnosis
Emergency Department HMO education series
2012
Cardiac failure
Emergency Department HMO education series
2012
Case C2 - Summary
Long standing heart failure with an acute
exacerbation due to new onset rapid AF
Treatment of AF amp heart failure
Antithrombotic strategy
Then rate control
Perhaps rhythm control
See review article re AF treatment
To be published early 2013 Australian Rural Doctor
Case D
Mid 60s male
Found SOB ++ in street
Ambulance called
In ED
SOB at rest
Doesnt want help
Funny smell
Further information
Dishevelled
HR 120 reg BP 9560 Sats 94 RA
Vomiting intermittently
What will you do
Further treatment and
investigation
Further history from patient and collateral
sources
Resuscitation
IV access fluids
Bloods ndash FBC UEC CMP Blood gas
pH 71 pCO2 20 pO2 90 HCO3 10 BE -16
Further treatment and
investigation
Further history from patient and collateral
sources
Resuscitation
IV access fluids
Bloods ndash FBC UEC CMP Blood gas
pH 71 pCO2 20 pO2 90 HCO3 10 BE -16
BSL gt30
Further treatment and
investigation
Treatment
IV fluids ndash caution with Na and cerebral oedema
IV insulin
001 ndash 01 unitskghr
aim for BSL 2mmolL drop per hour
Continue until metabolic correction
Monitor and correct K+ other electrolytes
Monitor urine ketones VBGABG
Identify precipitant
Resolution
Wife arrives and is relieved to find husband
Chairman of Rotary Club
UTI developed whilst wife away for weekend
Questions
Summary
Diagnosis of the breathless patient requires you to look for clueshellip The time course of the illness
Associated symptoms
Known diseases or risk factors for disease
Treatment of illnesses supported by evidence for pneumonia asthma PE AF etc
Interpretation of radiology best done with clinical context
Thankyou
Emergency Department HMO education series
2012
What else should I ask
Travel historyhellip
Other important symptoms of respiratory
disease
Cough
Acute
Chronic
Haemoptysis (cancer TB other infections)
Chest Pain
Daytime sleepiness (obstructive sleep apnea)
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Emergency Department HMO education series
2012
Investigations
If the CXR is normal (ish)hellip
Peak Flow 250min (how does this help us)
ABG on room air pH 75 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
Emergency Department HMO education series
2012
Investigations
If the CXR is normalhellip
Peak Flow 250min (how does this help us)
ABG on room air pH 75 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
Emergency Department HMO education series
2012
BBH Asthma protocol
Emergency Department HMO education series
2012
Investigations
If the CXR is normalhellip
Peak Flow 250min (how does this help us)
ABG on room air pH 75 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
Emergency Department HMO education series
2012
Investigations
If the CXR is normalhellip
Peak Flow 300min (how does this help us)
ABG on room air pH 75 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
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 httpwwwnationalasthmaorgauhealth-professionalstools-for-primary-careasthma-action-plansasthma-action-
plan-library
Asthma sticker
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 httpwwwnationalasthmaorgauhealth-professionalstools-for-primary-careasthma-action-plansasthma-action-plan-
library
Discharge checklist
Follow up referral letter to GP
Copy of letter with patient (optional)
Current asthma action plan
Triggers identified
Medications prescribed including
Relievers-short acting B agonists
Preventers-steroids
Symptom controllers-long acting B agonists (if prescribed)
Ensure medications will last until arranged review
Spacer or other delivery systems available and patient
understands use and care
Asthma handouts given (patient information fact sheet)
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 httpwwwnationalasthmaorgauhealth-professionalstools-for-primary-careasthma-action-plansasthma-action-
plan-library
Example action plan
Emergency Department HMO education series
2012
Case B3
22 yo man
Brought to the ED by his partner
Gradual onset of SOB
Now present for few hours
What else do you want to know
Emergency Department HMO education series
2012
Further history amp examination
No wheeze
Productive cough
No recent URTI
Childhood asthma (age
3-12) hay fever
No cardiac history
No risk factors for PE
RR 34 HR 110 SR BP
8965
Sat 87 RA
Dull R base with coarse
crackles
Emergency Department HMO education series
2012
Investigations
The CXR is hellip
ABG on room air
pH 730 CO2 55
O2 70 HCO3 18
What do the blood gases
show
How severe is the
problem
Emergency Department HMO education series
2012
What scoring tools for
pneumonia
SMARTCOP CURB-65 Sepsis guidelines
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
SMARTCOP
SMARTCOP
SMARTCOP
CURB 65
Various website and apps can assist you in
remembering them wwwmdcalccom
Emergency Department HMO education series
2012
Case B4 - Female in her 60rsquos
Sudden onset SOB (present now for 1 hour quite
severe) right sided pleuritic chest pain
Mild fever
Right total knee replacement 3 days ago
persistent leg swelling since yesterday
Non-smoker
No previous cardiorespiratory disease
Emergency Department HMO education series
2012
What is the differential
diagnosis
Emergency Department HMO education series
2012
What is the differential
diagnosis
Most likely
PE
Next likely
Pneumonia
Less likely
Pneumothorax
Arrhythmia
AMI
Emergency Department HMO education series
2012
On examination amp tests
Tachypnoea and some WOB
RR 24 T 376 HR 110 BP 11070
Sats 93 RA
Chest clear with normal percussion and normal breath
sounds
CXR normal
ABG pH 75 CO2 30mmHg p02 62mmHg on RA
Most likely diagnosis
What are Wells criteria
What are Wells criteria
PERC
D-Dimer
What test do you want to do
Emergency Department HMO education series
2012
What can you see
Emergency Department HMO education series
2012
Filling defect R main pulmonary trunk
Emergency Department HMO education series
2012
Emergency Department HMO education series
2012
Case C Man in 60rsquos
Woke this am very SOB and distressed ndash called
ambulance
Progressive SOB over 6 months
Chronic cough
Usually with white sputum
Now worse with no change in sputum colour
No associated fever
SOB in night ndash gets up
Ankles swollen recently
Heavy smoker (35 pack years)
Admission to local hospital 612 ago with chest pains
Emergency Department HMO education series
2012
Differential diagnosis
CCF with acute exacerbation
Chronic obstructive pulmonary disease
(COPD) with acute infective exacerbation
Anaemia
Emergency Department HMO education series
2012
Exam amp investigationshellip
Unwell RR 36 T 368 HR 90 SR BP 180102
Satrsquos 88 RA
Evidence of work of breathing and use of accessory muscles (which are these)
Pursed lip breathing
Prolonged expiration with wheeze
ABG pH 728 pCO2 60 pO2 55 HCO3 26
What do these show
Do you want a CXR
Emergency Department HMO education series
2012
Emergency Department HMO education series
2012
Diagnosis
Acute cardiac failure ndash APO
Most likely cause
Treatment
ECG ndash filed unsigned and
unseen
Emergency Department HMO education series
2012
Diagnosis
Acute cardiac failure ndash APO
Most likely cause
Treatment
Emergency Department HMO education series
2012
Diagnosis - APO
Acute cardiac failure
Treatment
Medications Nitroglycerin SL topical or IV titrated to avoid hypotension Most rapidly
venodilates reduces LV afterload and corrects myocardial ischaemia
Frusemide IV Despite universal use absolute efficacy is unclear
Ventilatory Assistance Non-invasive ventilation (NIV) reduces mortality by 40 particularly with CPAP
and reduces need to intubate
Emergency Department HMO education series
2012
Case C2 - Male in 60rsquos
Progressive SOB over 6 months worse over 24 hours
Orthopnoea Paroxysmal nocturnal dyspnoea (PND) SOA All present to a minor degree over the 6 months but worse for 24 hours
Palpitations (last 24 hours)
Previous AMI 4 years ago pace maker
Ex-smoker Hypertension (HT) diabetes
Emergency Department HMO education series
2012
Examination
Unwell looking with increased work of breathing
RR 26 afeb HR Irreg 130 BP 10070
Sat 90 RA
JVP 5cm
SOA ++
Displaced apex beat no cardiac murmurs 3rd heart sound present
Normal chest expansion but stony dull percussion in the bases (RgtL) bilateral inspiratory crepitations just above the dull areas
ECG ndash what is your diagnosis
Emergency Department HMO education series
2012
Cardiac failure
Emergency Department HMO education series
2012
Case C2 - Summary
Long standing heart failure with an acute
exacerbation due to new onset rapid AF
Treatment of AF amp heart failure
Antithrombotic strategy
Then rate control
Perhaps rhythm control
See review article re AF treatment
To be published early 2013 Australian Rural Doctor
Case D
Mid 60s male
Found SOB ++ in street
Ambulance called
In ED
SOB at rest
Doesnt want help
Funny smell
Further information
Dishevelled
HR 120 reg BP 9560 Sats 94 RA
Vomiting intermittently
What will you do
Further treatment and
investigation
Further history from patient and collateral
sources
Resuscitation
IV access fluids
Bloods ndash FBC UEC CMP Blood gas
pH 71 pCO2 20 pO2 90 HCO3 10 BE -16
Further treatment and
investigation
Further history from patient and collateral
sources
Resuscitation
IV access fluids
Bloods ndash FBC UEC CMP Blood gas
pH 71 pCO2 20 pO2 90 HCO3 10 BE -16
BSL gt30
Further treatment and
investigation
Treatment
IV fluids ndash caution with Na and cerebral oedema
IV insulin
001 ndash 01 unitskghr
aim for BSL 2mmolL drop per hour
Continue until metabolic correction
Monitor and correct K+ other electrolytes
Monitor urine ketones VBGABG
Identify precipitant
Resolution
Wife arrives and is relieved to find husband
Chairman of Rotary Club
UTI developed whilst wife away for weekend
Questions
Summary
Diagnosis of the breathless patient requires you to look for clueshellip The time course of the illness
Associated symptoms
Known diseases or risk factors for disease
Treatment of illnesses supported by evidence for pneumonia asthma PE AF etc
Interpretation of radiology best done with clinical context
Thankyou
Emergency Department HMO education series
2012
What else should I ask
Travel historyhellip
Other important symptoms of respiratory
disease
Cough
Acute
Chronic
Haemoptysis (cancer TB other infections)
Chest Pain
Daytime sleepiness (obstructive sleep apnea)
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Emergency Department HMO education series
2012
Investigations
If the CXR is normalhellip
Peak Flow 250min (how does this help us)
ABG on room air pH 75 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
Emergency Department HMO education series
2012
BBH Asthma protocol
Emergency Department HMO education series
2012
Investigations
If the CXR is normalhellip
Peak Flow 250min (how does this help us)
ABG on room air pH 75 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
Emergency Department HMO education series
2012
Investigations
If the CXR is normalhellip
Peak Flow 300min (how does this help us)
ABG on room air pH 75 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
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 httpwwwnationalasthmaorgauhealth-professionalstools-for-primary-careasthma-action-plansasthma-action-
plan-library
Asthma sticker
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 httpwwwnationalasthmaorgauhealth-professionalstools-for-primary-careasthma-action-plansasthma-action-plan-
library
Discharge checklist
Follow up referral letter to GP
Copy of letter with patient (optional)
Current asthma action plan
Triggers identified
Medications prescribed including
Relievers-short acting B agonists
Preventers-steroids
Symptom controllers-long acting B agonists (if prescribed)
Ensure medications will last until arranged review
Spacer or other delivery systems available and patient
understands use and care
Asthma handouts given (patient information fact sheet)
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 httpwwwnationalasthmaorgauhealth-professionalstools-for-primary-careasthma-action-plansasthma-action-
plan-library
Example action plan
Emergency Department HMO education series
2012
Case B3
22 yo man
Brought to the ED by his partner
Gradual onset of SOB
Now present for few hours
What else do you want to know
Emergency Department HMO education series
2012
Further history amp examination
No wheeze
Productive cough
No recent URTI
Childhood asthma (age
3-12) hay fever
No cardiac history
No risk factors for PE
RR 34 HR 110 SR BP
8965
Sat 87 RA
Dull R base with coarse
crackles
Emergency Department HMO education series
2012
Investigations
The CXR is hellip
ABG on room air
pH 730 CO2 55
O2 70 HCO3 18
What do the blood gases
show
How severe is the
problem
Emergency Department HMO education series
2012
What scoring tools for
pneumonia
SMARTCOP CURB-65 Sepsis guidelines
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
SMARTCOP
SMARTCOP
SMARTCOP
CURB 65
Various website and apps can assist you in
remembering them wwwmdcalccom
Emergency Department HMO education series
2012
Case B4 - Female in her 60rsquos
Sudden onset SOB (present now for 1 hour quite
severe) right sided pleuritic chest pain
Mild fever
Right total knee replacement 3 days ago
persistent leg swelling since yesterday
Non-smoker
No previous cardiorespiratory disease
Emergency Department HMO education series
2012
What is the differential
diagnosis
Emergency Department HMO education series
2012
What is the differential
diagnosis
Most likely
PE
Next likely
Pneumonia
Less likely
Pneumothorax
Arrhythmia
AMI
Emergency Department HMO education series
2012
On examination amp tests
Tachypnoea and some WOB
RR 24 T 376 HR 110 BP 11070
Sats 93 RA
Chest clear with normal percussion and normal breath
sounds
CXR normal
ABG pH 75 CO2 30mmHg p02 62mmHg on RA
Most likely diagnosis
What are Wells criteria
What are Wells criteria
PERC
D-Dimer
What test do you want to do
Emergency Department HMO education series
2012
What can you see
Emergency Department HMO education series
2012
Filling defect R main pulmonary trunk
Emergency Department HMO education series
2012
Emergency Department HMO education series
2012
Case C Man in 60rsquos
Woke this am very SOB and distressed ndash called
ambulance
Progressive SOB over 6 months
Chronic cough
Usually with white sputum
Now worse with no change in sputum colour
No associated fever
SOB in night ndash gets up
Ankles swollen recently
Heavy smoker (35 pack years)
Admission to local hospital 612 ago with chest pains
Emergency Department HMO education series
2012
Differential diagnosis
CCF with acute exacerbation
Chronic obstructive pulmonary disease
(COPD) with acute infective exacerbation
Anaemia
Emergency Department HMO education series
2012
Exam amp investigationshellip
Unwell RR 36 T 368 HR 90 SR BP 180102
Satrsquos 88 RA
Evidence of work of breathing and use of accessory muscles (which are these)
Pursed lip breathing
Prolonged expiration with wheeze
ABG pH 728 pCO2 60 pO2 55 HCO3 26
What do these show
Do you want a CXR
Emergency Department HMO education series
2012
Emergency Department HMO education series
2012
Diagnosis
Acute cardiac failure ndash APO
Most likely cause
Treatment
ECG ndash filed unsigned and
unseen
Emergency Department HMO education series
2012
Diagnosis
Acute cardiac failure ndash APO
Most likely cause
Treatment
Emergency Department HMO education series
2012
Diagnosis - APO
Acute cardiac failure
Treatment
Medications Nitroglycerin SL topical or IV titrated to avoid hypotension Most rapidly
venodilates reduces LV afterload and corrects myocardial ischaemia
Frusemide IV Despite universal use absolute efficacy is unclear
Ventilatory Assistance Non-invasive ventilation (NIV) reduces mortality by 40 particularly with CPAP
and reduces need to intubate
Emergency Department HMO education series
2012
Case C2 - Male in 60rsquos
Progressive SOB over 6 months worse over 24 hours
Orthopnoea Paroxysmal nocturnal dyspnoea (PND) SOA All present to a minor degree over the 6 months but worse for 24 hours
Palpitations (last 24 hours)
Previous AMI 4 years ago pace maker
Ex-smoker Hypertension (HT) diabetes
Emergency Department HMO education series
2012
Examination
Unwell looking with increased work of breathing
RR 26 afeb HR Irreg 130 BP 10070
Sat 90 RA
JVP 5cm
SOA ++
Displaced apex beat no cardiac murmurs 3rd heart sound present
Normal chest expansion but stony dull percussion in the bases (RgtL) bilateral inspiratory crepitations just above the dull areas
ECG ndash what is your diagnosis
Emergency Department HMO education series
2012
Cardiac failure
Emergency Department HMO education series
2012
Case C2 - Summary
Long standing heart failure with an acute
exacerbation due to new onset rapid AF
Treatment of AF amp heart failure
Antithrombotic strategy
Then rate control
Perhaps rhythm control
See review article re AF treatment
To be published early 2013 Australian Rural Doctor
Case D
Mid 60s male
Found SOB ++ in street
Ambulance called
In ED
SOB at rest
Doesnt want help
Funny smell
Further information
Dishevelled
HR 120 reg BP 9560 Sats 94 RA
Vomiting intermittently
What will you do
Further treatment and
investigation
Further history from patient and collateral
sources
Resuscitation
IV access fluids
Bloods ndash FBC UEC CMP Blood gas
pH 71 pCO2 20 pO2 90 HCO3 10 BE -16
Further treatment and
investigation
Further history from patient and collateral
sources
Resuscitation
IV access fluids
Bloods ndash FBC UEC CMP Blood gas
pH 71 pCO2 20 pO2 90 HCO3 10 BE -16
BSL gt30
Further treatment and
investigation
Treatment
IV fluids ndash caution with Na and cerebral oedema
IV insulin
001 ndash 01 unitskghr
aim for BSL 2mmolL drop per hour
Continue until metabolic correction
Monitor and correct K+ other electrolytes
Monitor urine ketones VBGABG
Identify precipitant
Resolution
Wife arrives and is relieved to find husband
Chairman of Rotary Club
UTI developed whilst wife away for weekend
Questions
Summary
Diagnosis of the breathless patient requires you to look for clueshellip The time course of the illness
Associated symptoms
Known diseases or risk factors for disease
Treatment of illnesses supported by evidence for pneumonia asthma PE AF etc
Interpretation of radiology best done with clinical context
Thankyou
Emergency Department HMO education series
2012
What else should I ask
Travel historyhellip
Other important symptoms of respiratory
disease
Cough
Acute
Chronic
Haemoptysis (cancer TB other infections)
Chest Pain
Daytime sleepiness (obstructive sleep apnea)
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Emergency Department HMO education series
2012
BBH Asthma protocol
Emergency Department HMO education series
2012
Investigations
If the CXR is normalhellip
Peak Flow 250min (how does this help us)
ABG on room air pH 75 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
Emergency Department HMO education series
2012
Investigations
If the CXR is normalhellip
Peak Flow 300min (how does this help us)
ABG on room air pH 75 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
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 httpwwwnationalasthmaorgauhealth-professionalstools-for-primary-careasthma-action-plansasthma-action-
plan-library
Asthma sticker
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 httpwwwnationalasthmaorgauhealth-professionalstools-for-primary-careasthma-action-plansasthma-action-plan-
library
Discharge checklist
Follow up referral letter to GP
Copy of letter with patient (optional)
Current asthma action plan
Triggers identified
Medications prescribed including
Relievers-short acting B agonists
Preventers-steroids
Symptom controllers-long acting B agonists (if prescribed)
Ensure medications will last until arranged review
Spacer or other delivery systems available and patient
understands use and care
Asthma handouts given (patient information fact sheet)
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 httpwwwnationalasthmaorgauhealth-professionalstools-for-primary-careasthma-action-plansasthma-action-
plan-library
Example action plan
Emergency Department HMO education series
2012
Case B3
22 yo man
Brought to the ED by his partner
Gradual onset of SOB
Now present for few hours
What else do you want to know
Emergency Department HMO education series
2012
Further history amp examination
No wheeze
Productive cough
No recent URTI
Childhood asthma (age
3-12) hay fever
No cardiac history
No risk factors for PE
RR 34 HR 110 SR BP
8965
Sat 87 RA
Dull R base with coarse
crackles
Emergency Department HMO education series
2012
Investigations
The CXR is hellip
ABG on room air
pH 730 CO2 55
O2 70 HCO3 18
What do the blood gases
show
How severe is the
problem
Emergency Department HMO education series
2012
What scoring tools for
pneumonia
SMARTCOP CURB-65 Sepsis guidelines
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
SMARTCOP
SMARTCOP
SMARTCOP
CURB 65
Various website and apps can assist you in
remembering them wwwmdcalccom
Emergency Department HMO education series
2012
Case B4 - Female in her 60rsquos
Sudden onset SOB (present now for 1 hour quite
severe) right sided pleuritic chest pain
Mild fever
Right total knee replacement 3 days ago
persistent leg swelling since yesterday
Non-smoker
No previous cardiorespiratory disease
Emergency Department HMO education series
2012
What is the differential
diagnosis
Emergency Department HMO education series
2012
What is the differential
diagnosis
Most likely
PE
Next likely
Pneumonia
Less likely
Pneumothorax
Arrhythmia
AMI
Emergency Department HMO education series
2012
On examination amp tests
Tachypnoea and some WOB
RR 24 T 376 HR 110 BP 11070
Sats 93 RA
Chest clear with normal percussion and normal breath
sounds
CXR normal
ABG pH 75 CO2 30mmHg p02 62mmHg on RA
Most likely diagnosis
What are Wells criteria
What are Wells criteria
PERC
D-Dimer
What test do you want to do
Emergency Department HMO education series
2012
What can you see
Emergency Department HMO education series
2012
Filling defect R main pulmonary trunk
Emergency Department HMO education series
2012
Emergency Department HMO education series
2012
Case C Man in 60rsquos
Woke this am very SOB and distressed ndash called
ambulance
Progressive SOB over 6 months
Chronic cough
Usually with white sputum
Now worse with no change in sputum colour
No associated fever
SOB in night ndash gets up
Ankles swollen recently
Heavy smoker (35 pack years)
Admission to local hospital 612 ago with chest pains
Emergency Department HMO education series
2012
Differential diagnosis
CCF with acute exacerbation
Chronic obstructive pulmonary disease
(COPD) with acute infective exacerbation
Anaemia
Emergency Department HMO education series
2012
Exam amp investigationshellip
Unwell RR 36 T 368 HR 90 SR BP 180102
Satrsquos 88 RA
Evidence of work of breathing and use of accessory muscles (which are these)
Pursed lip breathing
Prolonged expiration with wheeze
ABG pH 728 pCO2 60 pO2 55 HCO3 26
What do these show
Do you want a CXR
Emergency Department HMO education series
2012
Emergency Department HMO education series
2012
Diagnosis
Acute cardiac failure ndash APO
Most likely cause
Treatment
ECG ndash filed unsigned and
unseen
Emergency Department HMO education series
2012
Diagnosis
Acute cardiac failure ndash APO
Most likely cause
Treatment
Emergency Department HMO education series
2012
Diagnosis - APO
Acute cardiac failure
Treatment
Medications Nitroglycerin SL topical or IV titrated to avoid hypotension Most rapidly
venodilates reduces LV afterload and corrects myocardial ischaemia
Frusemide IV Despite universal use absolute efficacy is unclear
Ventilatory Assistance Non-invasive ventilation (NIV) reduces mortality by 40 particularly with CPAP
and reduces need to intubate
Emergency Department HMO education series
2012
Case C2 - Male in 60rsquos
Progressive SOB over 6 months worse over 24 hours
Orthopnoea Paroxysmal nocturnal dyspnoea (PND) SOA All present to a minor degree over the 6 months but worse for 24 hours
Palpitations (last 24 hours)
Previous AMI 4 years ago pace maker
Ex-smoker Hypertension (HT) diabetes
Emergency Department HMO education series
2012
Examination
Unwell looking with increased work of breathing
RR 26 afeb HR Irreg 130 BP 10070
Sat 90 RA
JVP 5cm
SOA ++
Displaced apex beat no cardiac murmurs 3rd heart sound present
Normal chest expansion but stony dull percussion in the bases (RgtL) bilateral inspiratory crepitations just above the dull areas
ECG ndash what is your diagnosis
Emergency Department HMO education series
2012
Cardiac failure
Emergency Department HMO education series
2012
Case C2 - Summary
Long standing heart failure with an acute
exacerbation due to new onset rapid AF
Treatment of AF amp heart failure
Antithrombotic strategy
Then rate control
Perhaps rhythm control
See review article re AF treatment
To be published early 2013 Australian Rural Doctor
Case D
Mid 60s male
Found SOB ++ in street
Ambulance called
In ED
SOB at rest
Doesnt want help
Funny smell
Further information
Dishevelled
HR 120 reg BP 9560 Sats 94 RA
Vomiting intermittently
What will you do
Further treatment and
investigation
Further history from patient and collateral
sources
Resuscitation
IV access fluids
Bloods ndash FBC UEC CMP Blood gas
pH 71 pCO2 20 pO2 90 HCO3 10 BE -16
Further treatment and
investigation
Further history from patient and collateral
sources
Resuscitation
IV access fluids
Bloods ndash FBC UEC CMP Blood gas
pH 71 pCO2 20 pO2 90 HCO3 10 BE -16
BSL gt30
Further treatment and
investigation
Treatment
IV fluids ndash caution with Na and cerebral oedema
IV insulin
001 ndash 01 unitskghr
aim for BSL 2mmolL drop per hour
Continue until metabolic correction
Monitor and correct K+ other electrolytes
Monitor urine ketones VBGABG
Identify precipitant
Resolution
Wife arrives and is relieved to find husband
Chairman of Rotary Club
UTI developed whilst wife away for weekend
Questions
Summary
Diagnosis of the breathless patient requires you to look for clueshellip The time course of the illness
Associated symptoms
Known diseases or risk factors for disease
Treatment of illnesses supported by evidence for pneumonia asthma PE AF etc
Interpretation of radiology best done with clinical context
Thankyou
Emergency Department HMO education series
2012
What else should I ask
Travel historyhellip
Other important symptoms of respiratory
disease
Cough
Acute
Chronic
Haemoptysis (cancer TB other infections)
Chest Pain
Daytime sleepiness (obstructive sleep apnea)
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Emergency Department HMO education series
2012
Investigations
If the CXR is normalhellip
Peak Flow 250min (how does this help us)
ABG on room air pH 75 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
Emergency Department HMO education series
2012
Investigations
If the CXR is normalhellip
Peak Flow 300min (how does this help us)
ABG on room air pH 75 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
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 httpwwwnationalasthmaorgauhealth-professionalstools-for-primary-careasthma-action-plansasthma-action-
plan-library
Asthma sticker
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 httpwwwnationalasthmaorgauhealth-professionalstools-for-primary-careasthma-action-plansasthma-action-plan-
library
Discharge checklist
Follow up referral letter to GP
Copy of letter with patient (optional)
Current asthma action plan
Triggers identified
Medications prescribed including
Relievers-short acting B agonists
Preventers-steroids
Symptom controllers-long acting B agonists (if prescribed)
Ensure medications will last until arranged review
Spacer or other delivery systems available and patient
understands use and care
Asthma handouts given (patient information fact sheet)
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 httpwwwnationalasthmaorgauhealth-professionalstools-for-primary-careasthma-action-plansasthma-action-
plan-library
Example action plan
Emergency Department HMO education series
2012
Case B3
22 yo man
Brought to the ED by his partner
Gradual onset of SOB
Now present for few hours
What else do you want to know
Emergency Department HMO education series
2012
Further history amp examination
No wheeze
Productive cough
No recent URTI
Childhood asthma (age
3-12) hay fever
No cardiac history
No risk factors for PE
RR 34 HR 110 SR BP
8965
Sat 87 RA
Dull R base with coarse
crackles
Emergency Department HMO education series
2012
Investigations
The CXR is hellip
ABG on room air
pH 730 CO2 55
O2 70 HCO3 18
What do the blood gases
show
How severe is the
problem
Emergency Department HMO education series
2012
What scoring tools for
pneumonia
SMARTCOP CURB-65 Sepsis guidelines
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
SMARTCOP
SMARTCOP
SMARTCOP
CURB 65
Various website and apps can assist you in
remembering them wwwmdcalccom
Emergency Department HMO education series
2012
Case B4 - Female in her 60rsquos
Sudden onset SOB (present now for 1 hour quite
severe) right sided pleuritic chest pain
Mild fever
Right total knee replacement 3 days ago
persistent leg swelling since yesterday
Non-smoker
No previous cardiorespiratory disease
Emergency Department HMO education series
2012
What is the differential
diagnosis
Emergency Department HMO education series
2012
What is the differential
diagnosis
Most likely
PE
Next likely
Pneumonia
Less likely
Pneumothorax
Arrhythmia
AMI
Emergency Department HMO education series
2012
On examination amp tests
Tachypnoea and some WOB
RR 24 T 376 HR 110 BP 11070
Sats 93 RA
Chest clear with normal percussion and normal breath
sounds
CXR normal
ABG pH 75 CO2 30mmHg p02 62mmHg on RA
Most likely diagnosis
What are Wells criteria
What are Wells criteria
PERC
D-Dimer
What test do you want to do
Emergency Department HMO education series
2012
What can you see
Emergency Department HMO education series
2012
Filling defect R main pulmonary trunk
Emergency Department HMO education series
2012
Emergency Department HMO education series
2012
Case C Man in 60rsquos
Woke this am very SOB and distressed ndash called
ambulance
Progressive SOB over 6 months
Chronic cough
Usually with white sputum
Now worse with no change in sputum colour
No associated fever
SOB in night ndash gets up
Ankles swollen recently
Heavy smoker (35 pack years)
Admission to local hospital 612 ago with chest pains
Emergency Department HMO education series
2012
Differential diagnosis
CCF with acute exacerbation
Chronic obstructive pulmonary disease
(COPD) with acute infective exacerbation
Anaemia
Emergency Department HMO education series
2012
Exam amp investigationshellip
Unwell RR 36 T 368 HR 90 SR BP 180102
Satrsquos 88 RA
Evidence of work of breathing and use of accessory muscles (which are these)
Pursed lip breathing
Prolonged expiration with wheeze
ABG pH 728 pCO2 60 pO2 55 HCO3 26
What do these show
Do you want a CXR
Emergency Department HMO education series
2012
Emergency Department HMO education series
2012
Diagnosis
Acute cardiac failure ndash APO
Most likely cause
Treatment
ECG ndash filed unsigned and
unseen
Emergency Department HMO education series
2012
Diagnosis
Acute cardiac failure ndash APO
Most likely cause
Treatment
Emergency Department HMO education series
2012
Diagnosis - APO
Acute cardiac failure
Treatment
Medications Nitroglycerin SL topical or IV titrated to avoid hypotension Most rapidly
venodilates reduces LV afterload and corrects myocardial ischaemia
Frusemide IV Despite universal use absolute efficacy is unclear
Ventilatory Assistance Non-invasive ventilation (NIV) reduces mortality by 40 particularly with CPAP
and reduces need to intubate
Emergency Department HMO education series
2012
Case C2 - Male in 60rsquos
Progressive SOB over 6 months worse over 24 hours
Orthopnoea Paroxysmal nocturnal dyspnoea (PND) SOA All present to a minor degree over the 6 months but worse for 24 hours
Palpitations (last 24 hours)
Previous AMI 4 years ago pace maker
Ex-smoker Hypertension (HT) diabetes
Emergency Department HMO education series
2012
Examination
Unwell looking with increased work of breathing
RR 26 afeb HR Irreg 130 BP 10070
Sat 90 RA
JVP 5cm
SOA ++
Displaced apex beat no cardiac murmurs 3rd heart sound present
Normal chest expansion but stony dull percussion in the bases (RgtL) bilateral inspiratory crepitations just above the dull areas
ECG ndash what is your diagnosis
Emergency Department HMO education series
2012
Cardiac failure
Emergency Department HMO education series
2012
Case C2 - Summary
Long standing heart failure with an acute
exacerbation due to new onset rapid AF
Treatment of AF amp heart failure
Antithrombotic strategy
Then rate control
Perhaps rhythm control
See review article re AF treatment
To be published early 2013 Australian Rural Doctor
Case D
Mid 60s male
Found SOB ++ in street
Ambulance called
In ED
SOB at rest
Doesnt want help
Funny smell
Further information
Dishevelled
HR 120 reg BP 9560 Sats 94 RA
Vomiting intermittently
What will you do
Further treatment and
investigation
Further history from patient and collateral
sources
Resuscitation
IV access fluids
Bloods ndash FBC UEC CMP Blood gas
pH 71 pCO2 20 pO2 90 HCO3 10 BE -16
Further treatment and
investigation
Further history from patient and collateral
sources
Resuscitation
IV access fluids
Bloods ndash FBC UEC CMP Blood gas
pH 71 pCO2 20 pO2 90 HCO3 10 BE -16
BSL gt30
Further treatment and
investigation
Treatment
IV fluids ndash caution with Na and cerebral oedema
IV insulin
001 ndash 01 unitskghr
aim for BSL 2mmolL drop per hour
Continue until metabolic correction
Monitor and correct K+ other electrolytes
Monitor urine ketones VBGABG
Identify precipitant
Resolution
Wife arrives and is relieved to find husband
Chairman of Rotary Club
UTI developed whilst wife away for weekend
Questions
Summary
Diagnosis of the breathless patient requires you to look for clueshellip The time course of the illness
Associated symptoms
Known diseases or risk factors for disease
Treatment of illnesses supported by evidence for pneumonia asthma PE AF etc
Interpretation of radiology best done with clinical context
Thankyou
Emergency Department HMO education series
2012
What else should I ask
Travel historyhellip
Other important symptoms of respiratory
disease
Cough
Acute
Chronic
Haemoptysis (cancer TB other infections)
Chest Pain
Daytime sleepiness (obstructive sleep apnea)
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Emergency Department HMO education series
2012
Investigations
If the CXR is normalhellip
Peak Flow 300min (how does this help us)
ABG on room air pH 75 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
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 httpwwwnationalasthmaorgauhealth-professionalstools-for-primary-careasthma-action-plansasthma-action-
plan-library
Asthma sticker
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 httpwwwnationalasthmaorgauhealth-professionalstools-for-primary-careasthma-action-plansasthma-action-plan-
library
Discharge checklist
Follow up referral letter to GP
Copy of letter with patient (optional)
Current asthma action plan
Triggers identified
Medications prescribed including
Relievers-short acting B agonists
Preventers-steroids
Symptom controllers-long acting B agonists (if prescribed)
Ensure medications will last until arranged review
Spacer or other delivery systems available and patient
understands use and care
Asthma handouts given (patient information fact sheet)
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 httpwwwnationalasthmaorgauhealth-professionalstools-for-primary-careasthma-action-plansasthma-action-
plan-library
Example action plan
Emergency Department HMO education series
2012
Case B3
22 yo man
Brought to the ED by his partner
Gradual onset of SOB
Now present for few hours
What else do you want to know
Emergency Department HMO education series
2012
Further history amp examination
No wheeze
Productive cough
No recent URTI
Childhood asthma (age
3-12) hay fever
No cardiac history
No risk factors for PE
RR 34 HR 110 SR BP
8965
Sat 87 RA
Dull R base with coarse
crackles
Emergency Department HMO education series
2012
Investigations
The CXR is hellip
ABG on room air
pH 730 CO2 55
O2 70 HCO3 18
What do the blood gases
show
How severe is the
problem
Emergency Department HMO education series
2012
What scoring tools for
pneumonia
SMARTCOP CURB-65 Sepsis guidelines
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
SMARTCOP
SMARTCOP
SMARTCOP
CURB 65
Various website and apps can assist you in
remembering them wwwmdcalccom
Emergency Department HMO education series
2012
Case B4 - Female in her 60rsquos
Sudden onset SOB (present now for 1 hour quite
severe) right sided pleuritic chest pain
Mild fever
Right total knee replacement 3 days ago
persistent leg swelling since yesterday
Non-smoker
No previous cardiorespiratory disease
Emergency Department HMO education series
2012
What is the differential
diagnosis
Emergency Department HMO education series
2012
What is the differential
diagnosis
Most likely
PE
Next likely
Pneumonia
Less likely
Pneumothorax
Arrhythmia
AMI
Emergency Department HMO education series
2012
On examination amp tests
Tachypnoea and some WOB
RR 24 T 376 HR 110 BP 11070
Sats 93 RA
Chest clear with normal percussion and normal breath
sounds
CXR normal
ABG pH 75 CO2 30mmHg p02 62mmHg on RA
Most likely diagnosis
What are Wells criteria
What are Wells criteria
PERC
D-Dimer
What test do you want to do
Emergency Department HMO education series
2012
What can you see
Emergency Department HMO education series
2012
Filling defect R main pulmonary trunk
Emergency Department HMO education series
2012
Emergency Department HMO education series
2012
Case C Man in 60rsquos
Woke this am very SOB and distressed ndash called
ambulance
Progressive SOB over 6 months
Chronic cough
Usually with white sputum
Now worse with no change in sputum colour
No associated fever
SOB in night ndash gets up
Ankles swollen recently
Heavy smoker (35 pack years)
Admission to local hospital 612 ago with chest pains
Emergency Department HMO education series
2012
Differential diagnosis
CCF with acute exacerbation
Chronic obstructive pulmonary disease
(COPD) with acute infective exacerbation
Anaemia
Emergency Department HMO education series
2012
Exam amp investigationshellip
Unwell RR 36 T 368 HR 90 SR BP 180102
Satrsquos 88 RA
Evidence of work of breathing and use of accessory muscles (which are these)
Pursed lip breathing
Prolonged expiration with wheeze
ABG pH 728 pCO2 60 pO2 55 HCO3 26
What do these show
Do you want a CXR
Emergency Department HMO education series
2012
Emergency Department HMO education series
2012
Diagnosis
Acute cardiac failure ndash APO
Most likely cause
Treatment
ECG ndash filed unsigned and
unseen
Emergency Department HMO education series
2012
Diagnosis
Acute cardiac failure ndash APO
Most likely cause
Treatment
Emergency Department HMO education series
2012
Diagnosis - APO
Acute cardiac failure
Treatment
Medications Nitroglycerin SL topical or IV titrated to avoid hypotension Most rapidly
venodilates reduces LV afterload and corrects myocardial ischaemia
Frusemide IV Despite universal use absolute efficacy is unclear
Ventilatory Assistance Non-invasive ventilation (NIV) reduces mortality by 40 particularly with CPAP
and reduces need to intubate
Emergency Department HMO education series
2012
Case C2 - Male in 60rsquos
Progressive SOB over 6 months worse over 24 hours
Orthopnoea Paroxysmal nocturnal dyspnoea (PND) SOA All present to a minor degree over the 6 months but worse for 24 hours
Palpitations (last 24 hours)
Previous AMI 4 years ago pace maker
Ex-smoker Hypertension (HT) diabetes
Emergency Department HMO education series
2012
Examination
Unwell looking with increased work of breathing
RR 26 afeb HR Irreg 130 BP 10070
Sat 90 RA
JVP 5cm
SOA ++
Displaced apex beat no cardiac murmurs 3rd heart sound present
Normal chest expansion but stony dull percussion in the bases (RgtL) bilateral inspiratory crepitations just above the dull areas
ECG ndash what is your diagnosis
Emergency Department HMO education series
2012
Cardiac failure
Emergency Department HMO education series
2012
Case C2 - Summary
Long standing heart failure with an acute
exacerbation due to new onset rapid AF
Treatment of AF amp heart failure
Antithrombotic strategy
Then rate control
Perhaps rhythm control
See review article re AF treatment
To be published early 2013 Australian Rural Doctor
Case D
Mid 60s male
Found SOB ++ in street
Ambulance called
In ED
SOB at rest
Doesnt want help
Funny smell
Further information
Dishevelled
HR 120 reg BP 9560 Sats 94 RA
Vomiting intermittently
What will you do
Further treatment and
investigation
Further history from patient and collateral
sources
Resuscitation
IV access fluids
Bloods ndash FBC UEC CMP Blood gas
pH 71 pCO2 20 pO2 90 HCO3 10 BE -16
Further treatment and
investigation
Further history from patient and collateral
sources
Resuscitation
IV access fluids
Bloods ndash FBC UEC CMP Blood gas
pH 71 pCO2 20 pO2 90 HCO3 10 BE -16
BSL gt30
Further treatment and
investigation
Treatment
IV fluids ndash caution with Na and cerebral oedema
IV insulin
001 ndash 01 unitskghr
aim for BSL 2mmolL drop per hour
Continue until metabolic correction
Monitor and correct K+ other electrolytes
Monitor urine ketones VBGABG
Identify precipitant
Resolution
Wife arrives and is relieved to find husband
Chairman of Rotary Club
UTI developed whilst wife away for weekend
Questions
Summary
Diagnosis of the breathless patient requires you to look for clueshellip The time course of the illness
Associated symptoms
Known diseases or risk factors for disease
Treatment of illnesses supported by evidence for pneumonia asthma PE AF etc
Interpretation of radiology best done with clinical context
Thankyou
Emergency Department HMO education series
2012
What else should I ask
Travel historyhellip
Other important symptoms of respiratory
disease
Cough
Acute
Chronic
Haemoptysis (cancer TB other infections)
Chest Pain
Daytime sleepiness (obstructive sleep apnea)
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
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 httpwwwnationalasthmaorgauhealth-professionalstools-for-primary-careasthma-action-plansasthma-action-
plan-library
Asthma sticker
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 httpwwwnationalasthmaorgauhealth-professionalstools-for-primary-careasthma-action-plansasthma-action-plan-
library
Discharge checklist
Follow up referral letter to GP
Copy of letter with patient (optional)
Current asthma action plan
Triggers identified
Medications prescribed including
Relievers-short acting B agonists
Preventers-steroids
Symptom controllers-long acting B agonists (if prescribed)
Ensure medications will last until arranged review
Spacer or other delivery systems available and patient
understands use and care
Asthma handouts given (patient information fact sheet)
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 httpwwwnationalasthmaorgauhealth-professionalstools-for-primary-careasthma-action-plansasthma-action-
plan-library
Example action plan
Emergency Department HMO education series
2012
Case B3
22 yo man
Brought to the ED by his partner
Gradual onset of SOB
Now present for few hours
What else do you want to know
Emergency Department HMO education series
2012
Further history amp examination
No wheeze
Productive cough
No recent URTI
Childhood asthma (age
3-12) hay fever
No cardiac history
No risk factors for PE
RR 34 HR 110 SR BP
8965
Sat 87 RA
Dull R base with coarse
crackles
Emergency Department HMO education series
2012
Investigations
The CXR is hellip
ABG on room air
pH 730 CO2 55
O2 70 HCO3 18
What do the blood gases
show
How severe is the
problem
Emergency Department HMO education series
2012
What scoring tools for
pneumonia
SMARTCOP CURB-65 Sepsis guidelines
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
SMARTCOP
SMARTCOP
SMARTCOP
CURB 65
Various website and apps can assist you in
remembering them wwwmdcalccom
Emergency Department HMO education series
2012
Case B4 - Female in her 60rsquos
Sudden onset SOB (present now for 1 hour quite
severe) right sided pleuritic chest pain
Mild fever
Right total knee replacement 3 days ago
persistent leg swelling since yesterday
Non-smoker
No previous cardiorespiratory disease
Emergency Department HMO education series
2012
What is the differential
diagnosis
Emergency Department HMO education series
2012
What is the differential
diagnosis
Most likely
PE
Next likely
Pneumonia
Less likely
Pneumothorax
Arrhythmia
AMI
Emergency Department HMO education series
2012
On examination amp tests
Tachypnoea and some WOB
RR 24 T 376 HR 110 BP 11070
Sats 93 RA
Chest clear with normal percussion and normal breath
sounds
CXR normal
ABG pH 75 CO2 30mmHg p02 62mmHg on RA
Most likely diagnosis
What are Wells criteria
What are Wells criteria
PERC
D-Dimer
What test do you want to do
Emergency Department HMO education series
2012
What can you see
Emergency Department HMO education series
2012
Filling defect R main pulmonary trunk
Emergency Department HMO education series
2012
Emergency Department HMO education series
2012
Case C Man in 60rsquos
Woke this am very SOB and distressed ndash called
ambulance
Progressive SOB over 6 months
Chronic cough
Usually with white sputum
Now worse with no change in sputum colour
No associated fever
SOB in night ndash gets up
Ankles swollen recently
Heavy smoker (35 pack years)
Admission to local hospital 612 ago with chest pains
Emergency Department HMO education series
2012
Differential diagnosis
CCF with acute exacerbation
Chronic obstructive pulmonary disease
(COPD) with acute infective exacerbation
Anaemia
Emergency Department HMO education series
2012
Exam amp investigationshellip
Unwell RR 36 T 368 HR 90 SR BP 180102
Satrsquos 88 RA
Evidence of work of breathing and use of accessory muscles (which are these)
Pursed lip breathing
Prolonged expiration with wheeze
ABG pH 728 pCO2 60 pO2 55 HCO3 26
What do these show
Do you want a CXR
Emergency Department HMO education series
2012
Emergency Department HMO education series
2012
Diagnosis
Acute cardiac failure ndash APO
Most likely cause
Treatment
ECG ndash filed unsigned and
unseen
Emergency Department HMO education series
2012
Diagnosis
Acute cardiac failure ndash APO
Most likely cause
Treatment
Emergency Department HMO education series
2012
Diagnosis - APO
Acute cardiac failure
Treatment
Medications Nitroglycerin SL topical or IV titrated to avoid hypotension Most rapidly
venodilates reduces LV afterload and corrects myocardial ischaemia
Frusemide IV Despite universal use absolute efficacy is unclear
Ventilatory Assistance Non-invasive ventilation (NIV) reduces mortality by 40 particularly with CPAP
and reduces need to intubate
Emergency Department HMO education series
2012
Case C2 - Male in 60rsquos
Progressive SOB over 6 months worse over 24 hours
Orthopnoea Paroxysmal nocturnal dyspnoea (PND) SOA All present to a minor degree over the 6 months but worse for 24 hours
Palpitations (last 24 hours)
Previous AMI 4 years ago pace maker
Ex-smoker Hypertension (HT) diabetes
Emergency Department HMO education series
2012
Examination
Unwell looking with increased work of breathing
RR 26 afeb HR Irreg 130 BP 10070
Sat 90 RA
JVP 5cm
SOA ++
Displaced apex beat no cardiac murmurs 3rd heart sound present
Normal chest expansion but stony dull percussion in the bases (RgtL) bilateral inspiratory crepitations just above the dull areas
ECG ndash what is your diagnosis
Emergency Department HMO education series
2012
Cardiac failure
Emergency Department HMO education series
2012
Case C2 - Summary
Long standing heart failure with an acute
exacerbation due to new onset rapid AF
Treatment of AF amp heart failure
Antithrombotic strategy
Then rate control
Perhaps rhythm control
See review article re AF treatment
To be published early 2013 Australian Rural Doctor
Case D
Mid 60s male
Found SOB ++ in street
Ambulance called
In ED
SOB at rest
Doesnt want help
Funny smell
Further information
Dishevelled
HR 120 reg BP 9560 Sats 94 RA
Vomiting intermittently
What will you do
Further treatment and
investigation
Further history from patient and collateral
sources
Resuscitation
IV access fluids
Bloods ndash FBC UEC CMP Blood gas
pH 71 pCO2 20 pO2 90 HCO3 10 BE -16
Further treatment and
investigation
Further history from patient and collateral
sources
Resuscitation
IV access fluids
Bloods ndash FBC UEC CMP Blood gas
pH 71 pCO2 20 pO2 90 HCO3 10 BE -16
BSL gt30
Further treatment and
investigation
Treatment
IV fluids ndash caution with Na and cerebral oedema
IV insulin
001 ndash 01 unitskghr
aim for BSL 2mmolL drop per hour
Continue until metabolic correction
Monitor and correct K+ other electrolytes
Monitor urine ketones VBGABG
Identify precipitant
Resolution
Wife arrives and is relieved to find husband
Chairman of Rotary Club
UTI developed whilst wife away for weekend
Questions
Summary
Diagnosis of the breathless patient requires you to look for clueshellip The time course of the illness
Associated symptoms
Known diseases or risk factors for disease
Treatment of illnesses supported by evidence for pneumonia asthma PE AF etc
Interpretation of radiology best done with clinical context
Thankyou
Emergency Department HMO education series
2012
What else should I ask
Travel historyhellip
Other important symptoms of respiratory
disease
Cough
Acute
Chronic
Haemoptysis (cancer TB other infections)
Chest Pain
Daytime sleepiness (obstructive sleep apnea)
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Asthma sticker
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 httpwwwnationalasthmaorgauhealth-professionalstools-for-primary-careasthma-action-plansasthma-action-plan-
library
Discharge checklist
Follow up referral letter to GP
Copy of letter with patient (optional)
Current asthma action plan
Triggers identified
Medications prescribed including
Relievers-short acting B agonists
Preventers-steroids
Symptom controllers-long acting B agonists (if prescribed)
Ensure medications will last until arranged review
Spacer or other delivery systems available and patient
understands use and care
Asthma handouts given (patient information fact sheet)
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 httpwwwnationalasthmaorgauhealth-professionalstools-for-primary-careasthma-action-plansasthma-action-
plan-library
Example action plan
Emergency Department HMO education series
2012
Case B3
22 yo man
Brought to the ED by his partner
Gradual onset of SOB
Now present for few hours
What else do you want to know
Emergency Department HMO education series
2012
Further history amp examination
No wheeze
Productive cough
No recent URTI
Childhood asthma (age
3-12) hay fever
No cardiac history
No risk factors for PE
RR 34 HR 110 SR BP
8965
Sat 87 RA
Dull R base with coarse
crackles
Emergency Department HMO education series
2012
Investigations
The CXR is hellip
ABG on room air
pH 730 CO2 55
O2 70 HCO3 18
What do the blood gases
show
How severe is the
problem
Emergency Department HMO education series
2012
What scoring tools for
pneumonia
SMARTCOP CURB-65 Sepsis guidelines
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
SMARTCOP
SMARTCOP
SMARTCOP
CURB 65
Various website and apps can assist you in
remembering them wwwmdcalccom
Emergency Department HMO education series
2012
Case B4 - Female in her 60rsquos
Sudden onset SOB (present now for 1 hour quite
severe) right sided pleuritic chest pain
Mild fever
Right total knee replacement 3 days ago
persistent leg swelling since yesterday
Non-smoker
No previous cardiorespiratory disease
Emergency Department HMO education series
2012
What is the differential
diagnosis
Emergency Department HMO education series
2012
What is the differential
diagnosis
Most likely
PE
Next likely
Pneumonia
Less likely
Pneumothorax
Arrhythmia
AMI
Emergency Department HMO education series
2012
On examination amp tests
Tachypnoea and some WOB
RR 24 T 376 HR 110 BP 11070
Sats 93 RA
Chest clear with normal percussion and normal breath
sounds
CXR normal
ABG pH 75 CO2 30mmHg p02 62mmHg on RA
Most likely diagnosis
What are Wells criteria
What are Wells criteria
PERC
D-Dimer
What test do you want to do
Emergency Department HMO education series
2012
What can you see
Emergency Department HMO education series
2012
Filling defect R main pulmonary trunk
Emergency Department HMO education series
2012
Emergency Department HMO education series
2012
Case C Man in 60rsquos
Woke this am very SOB and distressed ndash called
ambulance
Progressive SOB over 6 months
Chronic cough
Usually with white sputum
Now worse with no change in sputum colour
No associated fever
SOB in night ndash gets up
Ankles swollen recently
Heavy smoker (35 pack years)
Admission to local hospital 612 ago with chest pains
Emergency Department HMO education series
2012
Differential diagnosis
CCF with acute exacerbation
Chronic obstructive pulmonary disease
(COPD) with acute infective exacerbation
Anaemia
Emergency Department HMO education series
2012
Exam amp investigationshellip
Unwell RR 36 T 368 HR 90 SR BP 180102
Satrsquos 88 RA
Evidence of work of breathing and use of accessory muscles (which are these)
Pursed lip breathing
Prolonged expiration with wheeze
ABG pH 728 pCO2 60 pO2 55 HCO3 26
What do these show
Do you want a CXR
Emergency Department HMO education series
2012
Emergency Department HMO education series
2012
Diagnosis
Acute cardiac failure ndash APO
Most likely cause
Treatment
ECG ndash filed unsigned and
unseen
Emergency Department HMO education series
2012
Diagnosis
Acute cardiac failure ndash APO
Most likely cause
Treatment
Emergency Department HMO education series
2012
Diagnosis - APO
Acute cardiac failure
Treatment
Medications Nitroglycerin SL topical or IV titrated to avoid hypotension Most rapidly
venodilates reduces LV afterload and corrects myocardial ischaemia
Frusemide IV Despite universal use absolute efficacy is unclear
Ventilatory Assistance Non-invasive ventilation (NIV) reduces mortality by 40 particularly with CPAP
and reduces need to intubate
Emergency Department HMO education series
2012
Case C2 - Male in 60rsquos
Progressive SOB over 6 months worse over 24 hours
Orthopnoea Paroxysmal nocturnal dyspnoea (PND) SOA All present to a minor degree over the 6 months but worse for 24 hours
Palpitations (last 24 hours)
Previous AMI 4 years ago pace maker
Ex-smoker Hypertension (HT) diabetes
Emergency Department HMO education series
2012
Examination
Unwell looking with increased work of breathing
RR 26 afeb HR Irreg 130 BP 10070
Sat 90 RA
JVP 5cm
SOA ++
Displaced apex beat no cardiac murmurs 3rd heart sound present
Normal chest expansion but stony dull percussion in the bases (RgtL) bilateral inspiratory crepitations just above the dull areas
ECG ndash what is your diagnosis
Emergency Department HMO education series
2012
Cardiac failure
Emergency Department HMO education series
2012
Case C2 - Summary
Long standing heart failure with an acute
exacerbation due to new onset rapid AF
Treatment of AF amp heart failure
Antithrombotic strategy
Then rate control
Perhaps rhythm control
See review article re AF treatment
To be published early 2013 Australian Rural Doctor
Case D
Mid 60s male
Found SOB ++ in street
Ambulance called
In ED
SOB at rest
Doesnt want help
Funny smell
Further information
Dishevelled
HR 120 reg BP 9560 Sats 94 RA
Vomiting intermittently
What will you do
Further treatment and
investigation
Further history from patient and collateral
sources
Resuscitation
IV access fluids
Bloods ndash FBC UEC CMP Blood gas
pH 71 pCO2 20 pO2 90 HCO3 10 BE -16
Further treatment and
investigation
Further history from patient and collateral
sources
Resuscitation
IV access fluids
Bloods ndash FBC UEC CMP Blood gas
pH 71 pCO2 20 pO2 90 HCO3 10 BE -16
BSL gt30
Further treatment and
investigation
Treatment
IV fluids ndash caution with Na and cerebral oedema
IV insulin
001 ndash 01 unitskghr
aim for BSL 2mmolL drop per hour
Continue until metabolic correction
Monitor and correct K+ other electrolytes
Monitor urine ketones VBGABG
Identify precipitant
Resolution
Wife arrives and is relieved to find husband
Chairman of Rotary Club
UTI developed whilst wife away for weekend
Questions
Summary
Diagnosis of the breathless patient requires you to look for clueshellip The time course of the illness
Associated symptoms
Known diseases or risk factors for disease
Treatment of illnesses supported by evidence for pneumonia asthma PE AF etc
Interpretation of radiology best done with clinical context
Thankyou
Emergency Department HMO education series
2012
What else should I ask
Travel historyhellip
Other important symptoms of respiratory
disease
Cough
Acute
Chronic
Haemoptysis (cancer TB other infections)
Chest Pain
Daytime sleepiness (obstructive sleep apnea)
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
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 httpwwwnationalasthmaorgauhealth-professionalstools-for-primary-careasthma-action-plansasthma-action-plan-
library
Discharge checklist
Follow up referral letter to GP
Copy of letter with patient (optional)
Current asthma action plan
Triggers identified
Medications prescribed including
Relievers-short acting B agonists
Preventers-steroids
Symptom controllers-long acting B agonists (if prescribed)
Ensure medications will last until arranged review
Spacer or other delivery systems available and patient
understands use and care
Asthma handouts given (patient information fact sheet)
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 httpwwwnationalasthmaorgauhealth-professionalstools-for-primary-careasthma-action-plansasthma-action-
plan-library
Example action plan
Emergency Department HMO education series
2012
Case B3
22 yo man
Brought to the ED by his partner
Gradual onset of SOB
Now present for few hours
What else do you want to know
Emergency Department HMO education series
2012
Further history amp examination
No wheeze
Productive cough
No recent URTI
Childhood asthma (age
3-12) hay fever
No cardiac history
No risk factors for PE
RR 34 HR 110 SR BP
8965
Sat 87 RA
Dull R base with coarse
crackles
Emergency Department HMO education series
2012
Investigations
The CXR is hellip
ABG on room air
pH 730 CO2 55
O2 70 HCO3 18
What do the blood gases
show
How severe is the
problem
Emergency Department HMO education series
2012
What scoring tools for
pneumonia
SMARTCOP CURB-65 Sepsis guidelines
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
SMARTCOP
SMARTCOP
SMARTCOP
CURB 65
Various website and apps can assist you in
remembering them wwwmdcalccom
Emergency Department HMO education series
2012
Case B4 - Female in her 60rsquos
Sudden onset SOB (present now for 1 hour quite
severe) right sided pleuritic chest pain
Mild fever
Right total knee replacement 3 days ago
persistent leg swelling since yesterday
Non-smoker
No previous cardiorespiratory disease
Emergency Department HMO education series
2012
What is the differential
diagnosis
Emergency Department HMO education series
2012
What is the differential
diagnosis
Most likely
PE
Next likely
Pneumonia
Less likely
Pneumothorax
Arrhythmia
AMI
Emergency Department HMO education series
2012
On examination amp tests
Tachypnoea and some WOB
RR 24 T 376 HR 110 BP 11070
Sats 93 RA
Chest clear with normal percussion and normal breath
sounds
CXR normal
ABG pH 75 CO2 30mmHg p02 62mmHg on RA
Most likely diagnosis
What are Wells criteria
What are Wells criteria
PERC
D-Dimer
What test do you want to do
Emergency Department HMO education series
2012
What can you see
Emergency Department HMO education series
2012
Filling defect R main pulmonary trunk
Emergency Department HMO education series
2012
Emergency Department HMO education series
2012
Case C Man in 60rsquos
Woke this am very SOB and distressed ndash called
ambulance
Progressive SOB over 6 months
Chronic cough
Usually with white sputum
Now worse with no change in sputum colour
No associated fever
SOB in night ndash gets up
Ankles swollen recently
Heavy smoker (35 pack years)
Admission to local hospital 612 ago with chest pains
Emergency Department HMO education series
2012
Differential diagnosis
CCF with acute exacerbation
Chronic obstructive pulmonary disease
(COPD) with acute infective exacerbation
Anaemia
Emergency Department HMO education series
2012
Exam amp investigationshellip
Unwell RR 36 T 368 HR 90 SR BP 180102
Satrsquos 88 RA
Evidence of work of breathing and use of accessory muscles (which are these)
Pursed lip breathing
Prolonged expiration with wheeze
ABG pH 728 pCO2 60 pO2 55 HCO3 26
What do these show
Do you want a CXR
Emergency Department HMO education series
2012
Emergency Department HMO education series
2012
Diagnosis
Acute cardiac failure ndash APO
Most likely cause
Treatment
ECG ndash filed unsigned and
unseen
Emergency Department HMO education series
2012
Diagnosis
Acute cardiac failure ndash APO
Most likely cause
Treatment
Emergency Department HMO education series
2012
Diagnosis - APO
Acute cardiac failure
Treatment
Medications Nitroglycerin SL topical or IV titrated to avoid hypotension Most rapidly
venodilates reduces LV afterload and corrects myocardial ischaemia
Frusemide IV Despite universal use absolute efficacy is unclear
Ventilatory Assistance Non-invasive ventilation (NIV) reduces mortality by 40 particularly with CPAP
and reduces need to intubate
Emergency Department HMO education series
2012
Case C2 - Male in 60rsquos
Progressive SOB over 6 months worse over 24 hours
Orthopnoea Paroxysmal nocturnal dyspnoea (PND) SOA All present to a minor degree over the 6 months but worse for 24 hours
Palpitations (last 24 hours)
Previous AMI 4 years ago pace maker
Ex-smoker Hypertension (HT) diabetes
Emergency Department HMO education series
2012
Examination
Unwell looking with increased work of breathing
RR 26 afeb HR Irreg 130 BP 10070
Sat 90 RA
JVP 5cm
SOA ++
Displaced apex beat no cardiac murmurs 3rd heart sound present
Normal chest expansion but stony dull percussion in the bases (RgtL) bilateral inspiratory crepitations just above the dull areas
ECG ndash what is your diagnosis
Emergency Department HMO education series
2012
Cardiac failure
Emergency Department HMO education series
2012
Case C2 - Summary
Long standing heart failure with an acute
exacerbation due to new onset rapid AF
Treatment of AF amp heart failure
Antithrombotic strategy
Then rate control
Perhaps rhythm control
See review article re AF treatment
To be published early 2013 Australian Rural Doctor
Case D
Mid 60s male
Found SOB ++ in street
Ambulance called
In ED
SOB at rest
Doesnt want help
Funny smell
Further information
Dishevelled
HR 120 reg BP 9560 Sats 94 RA
Vomiting intermittently
What will you do
Further treatment and
investigation
Further history from patient and collateral
sources
Resuscitation
IV access fluids
Bloods ndash FBC UEC CMP Blood gas
pH 71 pCO2 20 pO2 90 HCO3 10 BE -16
Further treatment and
investigation
Further history from patient and collateral
sources
Resuscitation
IV access fluids
Bloods ndash FBC UEC CMP Blood gas
pH 71 pCO2 20 pO2 90 HCO3 10 BE -16
BSL gt30
Further treatment and
investigation
Treatment
IV fluids ndash caution with Na and cerebral oedema
IV insulin
001 ndash 01 unitskghr
aim for BSL 2mmolL drop per hour
Continue until metabolic correction
Monitor and correct K+ other electrolytes
Monitor urine ketones VBGABG
Identify precipitant
Resolution
Wife arrives and is relieved to find husband
Chairman of Rotary Club
UTI developed whilst wife away for weekend
Questions
Summary
Diagnosis of the breathless patient requires you to look for clueshellip The time course of the illness
Associated symptoms
Known diseases or risk factors for disease
Treatment of illnesses supported by evidence for pneumonia asthma PE AF etc
Interpretation of radiology best done with clinical context
Thankyou
Emergency Department HMO education series
2012
What else should I ask
Travel historyhellip
Other important symptoms of respiratory
disease
Cough
Acute
Chronic
Haemoptysis (cancer TB other infections)
Chest Pain
Daytime sleepiness (obstructive sleep apnea)
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Discharge checklist
Follow up referral letter to GP
Copy of letter with patient (optional)
Current asthma action plan
Triggers identified
Medications prescribed including
Relievers-short acting B agonists
Preventers-steroids
Symptom controllers-long acting B agonists (if prescribed)
Ensure medications will last until arranged review
Spacer or other delivery systems available and patient
understands use and care
Asthma handouts given (patient information fact sheet)
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 httpwwwnationalasthmaorgauhealth-professionalstools-for-primary-careasthma-action-plansasthma-action-
plan-library
Example action plan
Emergency Department HMO education series
2012
Case B3
22 yo man
Brought to the ED by his partner
Gradual onset of SOB
Now present for few hours
What else do you want to know
Emergency Department HMO education series
2012
Further history amp examination
No wheeze
Productive cough
No recent URTI
Childhood asthma (age
3-12) hay fever
No cardiac history
No risk factors for PE
RR 34 HR 110 SR BP
8965
Sat 87 RA
Dull R base with coarse
crackles
Emergency Department HMO education series
2012
Investigations
The CXR is hellip
ABG on room air
pH 730 CO2 55
O2 70 HCO3 18
What do the blood gases
show
How severe is the
problem
Emergency Department HMO education series
2012
What scoring tools for
pneumonia
SMARTCOP CURB-65 Sepsis guidelines
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
SMARTCOP
SMARTCOP
SMARTCOP
CURB 65
Various website and apps can assist you in
remembering them wwwmdcalccom
Emergency Department HMO education series
2012
Case B4 - Female in her 60rsquos
Sudden onset SOB (present now for 1 hour quite
severe) right sided pleuritic chest pain
Mild fever
Right total knee replacement 3 days ago
persistent leg swelling since yesterday
Non-smoker
No previous cardiorespiratory disease
Emergency Department HMO education series
2012
What is the differential
diagnosis
Emergency Department HMO education series
2012
What is the differential
diagnosis
Most likely
PE
Next likely
Pneumonia
Less likely
Pneumothorax
Arrhythmia
AMI
Emergency Department HMO education series
2012
On examination amp tests
Tachypnoea and some WOB
RR 24 T 376 HR 110 BP 11070
Sats 93 RA
Chest clear with normal percussion and normal breath
sounds
CXR normal
ABG pH 75 CO2 30mmHg p02 62mmHg on RA
Most likely diagnosis
What are Wells criteria
What are Wells criteria
PERC
D-Dimer
What test do you want to do
Emergency Department HMO education series
2012
What can you see
Emergency Department HMO education series
2012
Filling defect R main pulmonary trunk
Emergency Department HMO education series
2012
Emergency Department HMO education series
2012
Case C Man in 60rsquos
Woke this am very SOB and distressed ndash called
ambulance
Progressive SOB over 6 months
Chronic cough
Usually with white sputum
Now worse with no change in sputum colour
No associated fever
SOB in night ndash gets up
Ankles swollen recently
Heavy smoker (35 pack years)
Admission to local hospital 612 ago with chest pains
Emergency Department HMO education series
2012
Differential diagnosis
CCF with acute exacerbation
Chronic obstructive pulmonary disease
(COPD) with acute infective exacerbation
Anaemia
Emergency Department HMO education series
2012
Exam amp investigationshellip
Unwell RR 36 T 368 HR 90 SR BP 180102
Satrsquos 88 RA
Evidence of work of breathing and use of accessory muscles (which are these)
Pursed lip breathing
Prolonged expiration with wheeze
ABG pH 728 pCO2 60 pO2 55 HCO3 26
What do these show
Do you want a CXR
Emergency Department HMO education series
2012
Emergency Department HMO education series
2012
Diagnosis
Acute cardiac failure ndash APO
Most likely cause
Treatment
ECG ndash filed unsigned and
unseen
Emergency Department HMO education series
2012
Diagnosis
Acute cardiac failure ndash APO
Most likely cause
Treatment
Emergency Department HMO education series
2012
Diagnosis - APO
Acute cardiac failure
Treatment
Medications Nitroglycerin SL topical or IV titrated to avoid hypotension Most rapidly
venodilates reduces LV afterload and corrects myocardial ischaemia
Frusemide IV Despite universal use absolute efficacy is unclear
Ventilatory Assistance Non-invasive ventilation (NIV) reduces mortality by 40 particularly with CPAP
and reduces need to intubate
Emergency Department HMO education series
2012
Case C2 - Male in 60rsquos
Progressive SOB over 6 months worse over 24 hours
Orthopnoea Paroxysmal nocturnal dyspnoea (PND) SOA All present to a minor degree over the 6 months but worse for 24 hours
Palpitations (last 24 hours)
Previous AMI 4 years ago pace maker
Ex-smoker Hypertension (HT) diabetes
Emergency Department HMO education series
2012
Examination
Unwell looking with increased work of breathing
RR 26 afeb HR Irreg 130 BP 10070
Sat 90 RA
JVP 5cm
SOA ++
Displaced apex beat no cardiac murmurs 3rd heart sound present
Normal chest expansion but stony dull percussion in the bases (RgtL) bilateral inspiratory crepitations just above the dull areas
ECG ndash what is your diagnosis
Emergency Department HMO education series
2012
Cardiac failure
Emergency Department HMO education series
2012
Case C2 - Summary
Long standing heart failure with an acute
exacerbation due to new onset rapid AF
Treatment of AF amp heart failure
Antithrombotic strategy
Then rate control
Perhaps rhythm control
See review article re AF treatment
To be published early 2013 Australian Rural Doctor
Case D
Mid 60s male
Found SOB ++ in street
Ambulance called
In ED
SOB at rest
Doesnt want help
Funny smell
Further information
Dishevelled
HR 120 reg BP 9560 Sats 94 RA
Vomiting intermittently
What will you do
Further treatment and
investigation
Further history from patient and collateral
sources
Resuscitation
IV access fluids
Bloods ndash FBC UEC CMP Blood gas
pH 71 pCO2 20 pO2 90 HCO3 10 BE -16
Further treatment and
investigation
Further history from patient and collateral
sources
Resuscitation
IV access fluids
Bloods ndash FBC UEC CMP Blood gas
pH 71 pCO2 20 pO2 90 HCO3 10 BE -16
BSL gt30
Further treatment and
investigation
Treatment
IV fluids ndash caution with Na and cerebral oedema
IV insulin
001 ndash 01 unitskghr
aim for BSL 2mmolL drop per hour
Continue until metabolic correction
Monitor and correct K+ other electrolytes
Monitor urine ketones VBGABG
Identify precipitant
Resolution
Wife arrives and is relieved to find husband
Chairman of Rotary Club
UTI developed whilst wife away for weekend
Questions
Summary
Diagnosis of the breathless patient requires you to look for clueshellip The time course of the illness
Associated symptoms
Known diseases or risk factors for disease
Treatment of illnesses supported by evidence for pneumonia asthma PE AF etc
Interpretation of radiology best done with clinical context
Thankyou
Emergency Department HMO education series
2012
What else should I ask
Travel historyhellip
Other important symptoms of respiratory
disease
Cough
Acute
Chronic
Haemoptysis (cancer TB other infections)
Chest Pain
Daytime sleepiness (obstructive sleep apnea)
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
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 httpwwwnationalasthmaorgauhealth-professionalstools-for-primary-careasthma-action-plansasthma-action-
plan-library
Example action plan
Emergency Department HMO education series
2012
Case B3
22 yo man
Brought to the ED by his partner
Gradual onset of SOB
Now present for few hours
What else do you want to know
Emergency Department HMO education series
2012
Further history amp examination
No wheeze
Productive cough
No recent URTI
Childhood asthma (age
3-12) hay fever
No cardiac history
No risk factors for PE
RR 34 HR 110 SR BP
8965
Sat 87 RA
Dull R base with coarse
crackles
Emergency Department HMO education series
2012
Investigations
The CXR is hellip
ABG on room air
pH 730 CO2 55
O2 70 HCO3 18
What do the blood gases
show
How severe is the
problem
Emergency Department HMO education series
2012
What scoring tools for
pneumonia
SMARTCOP CURB-65 Sepsis guidelines
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
SMARTCOP
SMARTCOP
SMARTCOP
CURB 65
Various website and apps can assist you in
remembering them wwwmdcalccom
Emergency Department HMO education series
2012
Case B4 - Female in her 60rsquos
Sudden onset SOB (present now for 1 hour quite
severe) right sided pleuritic chest pain
Mild fever
Right total knee replacement 3 days ago
persistent leg swelling since yesterday
Non-smoker
No previous cardiorespiratory disease
Emergency Department HMO education series
2012
What is the differential
diagnosis
Emergency Department HMO education series
2012
What is the differential
diagnosis
Most likely
PE
Next likely
Pneumonia
Less likely
Pneumothorax
Arrhythmia
AMI
Emergency Department HMO education series
2012
On examination amp tests
Tachypnoea and some WOB
RR 24 T 376 HR 110 BP 11070
Sats 93 RA
Chest clear with normal percussion and normal breath
sounds
CXR normal
ABG pH 75 CO2 30mmHg p02 62mmHg on RA
Most likely diagnosis
What are Wells criteria
What are Wells criteria
PERC
D-Dimer
What test do you want to do
Emergency Department HMO education series
2012
What can you see
Emergency Department HMO education series
2012
Filling defect R main pulmonary trunk
Emergency Department HMO education series
2012
Emergency Department HMO education series
2012
Case C Man in 60rsquos
Woke this am very SOB and distressed ndash called
ambulance
Progressive SOB over 6 months
Chronic cough
Usually with white sputum
Now worse with no change in sputum colour
No associated fever
SOB in night ndash gets up
Ankles swollen recently
Heavy smoker (35 pack years)
Admission to local hospital 612 ago with chest pains
Emergency Department HMO education series
2012
Differential diagnosis
CCF with acute exacerbation
Chronic obstructive pulmonary disease
(COPD) with acute infective exacerbation
Anaemia
Emergency Department HMO education series
2012
Exam amp investigationshellip
Unwell RR 36 T 368 HR 90 SR BP 180102
Satrsquos 88 RA
Evidence of work of breathing and use of accessory muscles (which are these)
Pursed lip breathing
Prolonged expiration with wheeze
ABG pH 728 pCO2 60 pO2 55 HCO3 26
What do these show
Do you want a CXR
Emergency Department HMO education series
2012
Emergency Department HMO education series
2012
Diagnosis
Acute cardiac failure ndash APO
Most likely cause
Treatment
ECG ndash filed unsigned and
unseen
Emergency Department HMO education series
2012
Diagnosis
Acute cardiac failure ndash APO
Most likely cause
Treatment
Emergency Department HMO education series
2012
Diagnosis - APO
Acute cardiac failure
Treatment
Medications Nitroglycerin SL topical or IV titrated to avoid hypotension Most rapidly
venodilates reduces LV afterload and corrects myocardial ischaemia
Frusemide IV Despite universal use absolute efficacy is unclear
Ventilatory Assistance Non-invasive ventilation (NIV) reduces mortality by 40 particularly with CPAP
and reduces need to intubate
Emergency Department HMO education series
2012
Case C2 - Male in 60rsquos
Progressive SOB over 6 months worse over 24 hours
Orthopnoea Paroxysmal nocturnal dyspnoea (PND) SOA All present to a minor degree over the 6 months but worse for 24 hours
Palpitations (last 24 hours)
Previous AMI 4 years ago pace maker
Ex-smoker Hypertension (HT) diabetes
Emergency Department HMO education series
2012
Examination
Unwell looking with increased work of breathing
RR 26 afeb HR Irreg 130 BP 10070
Sat 90 RA
JVP 5cm
SOA ++
Displaced apex beat no cardiac murmurs 3rd heart sound present
Normal chest expansion but stony dull percussion in the bases (RgtL) bilateral inspiratory crepitations just above the dull areas
ECG ndash what is your diagnosis
Emergency Department HMO education series
2012
Cardiac failure
Emergency Department HMO education series
2012
Case C2 - Summary
Long standing heart failure with an acute
exacerbation due to new onset rapid AF
Treatment of AF amp heart failure
Antithrombotic strategy
Then rate control
Perhaps rhythm control
See review article re AF treatment
To be published early 2013 Australian Rural Doctor
Case D
Mid 60s male
Found SOB ++ in street
Ambulance called
In ED
SOB at rest
Doesnt want help
Funny smell
Further information
Dishevelled
HR 120 reg BP 9560 Sats 94 RA
Vomiting intermittently
What will you do
Further treatment and
investigation
Further history from patient and collateral
sources
Resuscitation
IV access fluids
Bloods ndash FBC UEC CMP Blood gas
pH 71 pCO2 20 pO2 90 HCO3 10 BE -16
Further treatment and
investigation
Further history from patient and collateral
sources
Resuscitation
IV access fluids
Bloods ndash FBC UEC CMP Blood gas
pH 71 pCO2 20 pO2 90 HCO3 10 BE -16
BSL gt30
Further treatment and
investigation
Treatment
IV fluids ndash caution with Na and cerebral oedema
IV insulin
001 ndash 01 unitskghr
aim for BSL 2mmolL drop per hour
Continue until metabolic correction
Monitor and correct K+ other electrolytes
Monitor urine ketones VBGABG
Identify precipitant
Resolution
Wife arrives and is relieved to find husband
Chairman of Rotary Club
UTI developed whilst wife away for weekend
Questions
Summary
Diagnosis of the breathless patient requires you to look for clueshellip The time course of the illness
Associated symptoms
Known diseases or risk factors for disease
Treatment of illnesses supported by evidence for pneumonia asthma PE AF etc
Interpretation of radiology best done with clinical context
Thankyou
Emergency Department HMO education series
2012
What else should I ask
Travel historyhellip
Other important symptoms of respiratory
disease
Cough
Acute
Chronic
Haemoptysis (cancer TB other infections)
Chest Pain
Daytime sleepiness (obstructive sleep apnea)
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Example action plan
Emergency Department HMO education series
2012
Case B3
22 yo man
Brought to the ED by his partner
Gradual onset of SOB
Now present for few hours
What else do you want to know
Emergency Department HMO education series
2012
Further history amp examination
No wheeze
Productive cough
No recent URTI
Childhood asthma (age
3-12) hay fever
No cardiac history
No risk factors for PE
RR 34 HR 110 SR BP
8965
Sat 87 RA
Dull R base with coarse
crackles
Emergency Department HMO education series
2012
Investigations
The CXR is hellip
ABG on room air
pH 730 CO2 55
O2 70 HCO3 18
What do the blood gases
show
How severe is the
problem
Emergency Department HMO education series
2012
What scoring tools for
pneumonia
SMARTCOP CURB-65 Sepsis guidelines
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
SMARTCOP
SMARTCOP
SMARTCOP
CURB 65
Various website and apps can assist you in
remembering them wwwmdcalccom
Emergency Department HMO education series
2012
Case B4 - Female in her 60rsquos
Sudden onset SOB (present now for 1 hour quite
severe) right sided pleuritic chest pain
Mild fever
Right total knee replacement 3 days ago
persistent leg swelling since yesterday
Non-smoker
No previous cardiorespiratory disease
Emergency Department HMO education series
2012
What is the differential
diagnosis
Emergency Department HMO education series
2012
What is the differential
diagnosis
Most likely
PE
Next likely
Pneumonia
Less likely
Pneumothorax
Arrhythmia
AMI
Emergency Department HMO education series
2012
On examination amp tests
Tachypnoea and some WOB
RR 24 T 376 HR 110 BP 11070
Sats 93 RA
Chest clear with normal percussion and normal breath
sounds
CXR normal
ABG pH 75 CO2 30mmHg p02 62mmHg on RA
Most likely diagnosis
What are Wells criteria
What are Wells criteria
PERC
D-Dimer
What test do you want to do
Emergency Department HMO education series
2012
What can you see
Emergency Department HMO education series
2012
Filling defect R main pulmonary trunk
Emergency Department HMO education series
2012
Emergency Department HMO education series
2012
Case C Man in 60rsquos
Woke this am very SOB and distressed ndash called
ambulance
Progressive SOB over 6 months
Chronic cough
Usually with white sputum
Now worse with no change in sputum colour
No associated fever
SOB in night ndash gets up
Ankles swollen recently
Heavy smoker (35 pack years)
Admission to local hospital 612 ago with chest pains
Emergency Department HMO education series
2012
Differential diagnosis
CCF with acute exacerbation
Chronic obstructive pulmonary disease
(COPD) with acute infective exacerbation
Anaemia
Emergency Department HMO education series
2012
Exam amp investigationshellip
Unwell RR 36 T 368 HR 90 SR BP 180102
Satrsquos 88 RA
Evidence of work of breathing and use of accessory muscles (which are these)
Pursed lip breathing
Prolonged expiration with wheeze
ABG pH 728 pCO2 60 pO2 55 HCO3 26
What do these show
Do you want a CXR
Emergency Department HMO education series
2012
Emergency Department HMO education series
2012
Diagnosis
Acute cardiac failure ndash APO
Most likely cause
Treatment
ECG ndash filed unsigned and
unseen
Emergency Department HMO education series
2012
Diagnosis
Acute cardiac failure ndash APO
Most likely cause
Treatment
Emergency Department HMO education series
2012
Diagnosis - APO
Acute cardiac failure
Treatment
Medications Nitroglycerin SL topical or IV titrated to avoid hypotension Most rapidly
venodilates reduces LV afterload and corrects myocardial ischaemia
Frusemide IV Despite universal use absolute efficacy is unclear
Ventilatory Assistance Non-invasive ventilation (NIV) reduces mortality by 40 particularly with CPAP
and reduces need to intubate
Emergency Department HMO education series
2012
Case C2 - Male in 60rsquos
Progressive SOB over 6 months worse over 24 hours
Orthopnoea Paroxysmal nocturnal dyspnoea (PND) SOA All present to a minor degree over the 6 months but worse for 24 hours
Palpitations (last 24 hours)
Previous AMI 4 years ago pace maker
Ex-smoker Hypertension (HT) diabetes
Emergency Department HMO education series
2012
Examination
Unwell looking with increased work of breathing
RR 26 afeb HR Irreg 130 BP 10070
Sat 90 RA
JVP 5cm
SOA ++
Displaced apex beat no cardiac murmurs 3rd heart sound present
Normal chest expansion but stony dull percussion in the bases (RgtL) bilateral inspiratory crepitations just above the dull areas
ECG ndash what is your diagnosis
Emergency Department HMO education series
2012
Cardiac failure
Emergency Department HMO education series
2012
Case C2 - Summary
Long standing heart failure with an acute
exacerbation due to new onset rapid AF
Treatment of AF amp heart failure
Antithrombotic strategy
Then rate control
Perhaps rhythm control
See review article re AF treatment
To be published early 2013 Australian Rural Doctor
Case D
Mid 60s male
Found SOB ++ in street
Ambulance called
In ED
SOB at rest
Doesnt want help
Funny smell
Further information
Dishevelled
HR 120 reg BP 9560 Sats 94 RA
Vomiting intermittently
What will you do
Further treatment and
investigation
Further history from patient and collateral
sources
Resuscitation
IV access fluids
Bloods ndash FBC UEC CMP Blood gas
pH 71 pCO2 20 pO2 90 HCO3 10 BE -16
Further treatment and
investigation
Further history from patient and collateral
sources
Resuscitation
IV access fluids
Bloods ndash FBC UEC CMP Blood gas
pH 71 pCO2 20 pO2 90 HCO3 10 BE -16
BSL gt30
Further treatment and
investigation
Treatment
IV fluids ndash caution with Na and cerebral oedema
IV insulin
001 ndash 01 unitskghr
aim for BSL 2mmolL drop per hour
Continue until metabolic correction
Monitor and correct K+ other electrolytes
Monitor urine ketones VBGABG
Identify precipitant
Resolution
Wife arrives and is relieved to find husband
Chairman of Rotary Club
UTI developed whilst wife away for weekend
Questions
Summary
Diagnosis of the breathless patient requires you to look for clueshellip The time course of the illness
Associated symptoms
Known diseases or risk factors for disease
Treatment of illnesses supported by evidence for pneumonia asthma PE AF etc
Interpretation of radiology best done with clinical context
Thankyou
Emergency Department HMO education series
2012
What else should I ask
Travel historyhellip
Other important symptoms of respiratory
disease
Cough
Acute
Chronic
Haemoptysis (cancer TB other infections)
Chest Pain
Daytime sleepiness (obstructive sleep apnea)
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Emergency Department HMO education series
2012
Case B3
22 yo man
Brought to the ED by his partner
Gradual onset of SOB
Now present for few hours
What else do you want to know
Emergency Department HMO education series
2012
Further history amp examination
No wheeze
Productive cough
No recent URTI
Childhood asthma (age
3-12) hay fever
No cardiac history
No risk factors for PE
RR 34 HR 110 SR BP
8965
Sat 87 RA
Dull R base with coarse
crackles
Emergency Department HMO education series
2012
Investigations
The CXR is hellip
ABG on room air
pH 730 CO2 55
O2 70 HCO3 18
What do the blood gases
show
How severe is the
problem
Emergency Department HMO education series
2012
What scoring tools for
pneumonia
SMARTCOP CURB-65 Sepsis guidelines
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
SMARTCOP
SMARTCOP
SMARTCOP
CURB 65
Various website and apps can assist you in
remembering them wwwmdcalccom
Emergency Department HMO education series
2012
Case B4 - Female in her 60rsquos
Sudden onset SOB (present now for 1 hour quite
severe) right sided pleuritic chest pain
Mild fever
Right total knee replacement 3 days ago
persistent leg swelling since yesterday
Non-smoker
No previous cardiorespiratory disease
Emergency Department HMO education series
2012
What is the differential
diagnosis
Emergency Department HMO education series
2012
What is the differential
diagnosis
Most likely
PE
Next likely
Pneumonia
Less likely
Pneumothorax
Arrhythmia
AMI
Emergency Department HMO education series
2012
On examination amp tests
Tachypnoea and some WOB
RR 24 T 376 HR 110 BP 11070
Sats 93 RA
Chest clear with normal percussion and normal breath
sounds
CXR normal
ABG pH 75 CO2 30mmHg p02 62mmHg on RA
Most likely diagnosis
What are Wells criteria
What are Wells criteria
PERC
D-Dimer
What test do you want to do
Emergency Department HMO education series
2012
What can you see
Emergency Department HMO education series
2012
Filling defect R main pulmonary trunk
Emergency Department HMO education series
2012
Emergency Department HMO education series
2012
Case C Man in 60rsquos
Woke this am very SOB and distressed ndash called
ambulance
Progressive SOB over 6 months
Chronic cough
Usually with white sputum
Now worse with no change in sputum colour
No associated fever
SOB in night ndash gets up
Ankles swollen recently
Heavy smoker (35 pack years)
Admission to local hospital 612 ago with chest pains
Emergency Department HMO education series
2012
Differential diagnosis
CCF with acute exacerbation
Chronic obstructive pulmonary disease
(COPD) with acute infective exacerbation
Anaemia
Emergency Department HMO education series
2012
Exam amp investigationshellip
Unwell RR 36 T 368 HR 90 SR BP 180102
Satrsquos 88 RA
Evidence of work of breathing and use of accessory muscles (which are these)
Pursed lip breathing
Prolonged expiration with wheeze
ABG pH 728 pCO2 60 pO2 55 HCO3 26
What do these show
Do you want a CXR
Emergency Department HMO education series
2012
Emergency Department HMO education series
2012
Diagnosis
Acute cardiac failure ndash APO
Most likely cause
Treatment
ECG ndash filed unsigned and
unseen
Emergency Department HMO education series
2012
Diagnosis
Acute cardiac failure ndash APO
Most likely cause
Treatment
Emergency Department HMO education series
2012
Diagnosis - APO
Acute cardiac failure
Treatment
Medications Nitroglycerin SL topical or IV titrated to avoid hypotension Most rapidly
venodilates reduces LV afterload and corrects myocardial ischaemia
Frusemide IV Despite universal use absolute efficacy is unclear
Ventilatory Assistance Non-invasive ventilation (NIV) reduces mortality by 40 particularly with CPAP
and reduces need to intubate
Emergency Department HMO education series
2012
Case C2 - Male in 60rsquos
Progressive SOB over 6 months worse over 24 hours
Orthopnoea Paroxysmal nocturnal dyspnoea (PND) SOA All present to a minor degree over the 6 months but worse for 24 hours
Palpitations (last 24 hours)
Previous AMI 4 years ago pace maker
Ex-smoker Hypertension (HT) diabetes
Emergency Department HMO education series
2012
Examination
Unwell looking with increased work of breathing
RR 26 afeb HR Irreg 130 BP 10070
Sat 90 RA
JVP 5cm
SOA ++
Displaced apex beat no cardiac murmurs 3rd heart sound present
Normal chest expansion but stony dull percussion in the bases (RgtL) bilateral inspiratory crepitations just above the dull areas
ECG ndash what is your diagnosis
Emergency Department HMO education series
2012
Cardiac failure
Emergency Department HMO education series
2012
Case C2 - Summary
Long standing heart failure with an acute
exacerbation due to new onset rapid AF
Treatment of AF amp heart failure
Antithrombotic strategy
Then rate control
Perhaps rhythm control
See review article re AF treatment
To be published early 2013 Australian Rural Doctor
Case D
Mid 60s male
Found SOB ++ in street
Ambulance called
In ED
SOB at rest
Doesnt want help
Funny smell
Further information
Dishevelled
HR 120 reg BP 9560 Sats 94 RA
Vomiting intermittently
What will you do
Further treatment and
investigation
Further history from patient and collateral
sources
Resuscitation
IV access fluids
Bloods ndash FBC UEC CMP Blood gas
pH 71 pCO2 20 pO2 90 HCO3 10 BE -16
Further treatment and
investigation
Further history from patient and collateral
sources
Resuscitation
IV access fluids
Bloods ndash FBC UEC CMP Blood gas
pH 71 pCO2 20 pO2 90 HCO3 10 BE -16
BSL gt30
Further treatment and
investigation
Treatment
IV fluids ndash caution with Na and cerebral oedema
IV insulin
001 ndash 01 unitskghr
aim for BSL 2mmolL drop per hour
Continue until metabolic correction
Monitor and correct K+ other electrolytes
Monitor urine ketones VBGABG
Identify precipitant
Resolution
Wife arrives and is relieved to find husband
Chairman of Rotary Club
UTI developed whilst wife away for weekend
Questions
Summary
Diagnosis of the breathless patient requires you to look for clueshellip The time course of the illness
Associated symptoms
Known diseases or risk factors for disease
Treatment of illnesses supported by evidence for pneumonia asthma PE AF etc
Interpretation of radiology best done with clinical context
Thankyou
Emergency Department HMO education series
2012
What else should I ask
Travel historyhellip
Other important symptoms of respiratory
disease
Cough
Acute
Chronic
Haemoptysis (cancer TB other infections)
Chest Pain
Daytime sleepiness (obstructive sleep apnea)
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Emergency Department HMO education series
2012
Further history amp examination
No wheeze
Productive cough
No recent URTI
Childhood asthma (age
3-12) hay fever
No cardiac history
No risk factors for PE
RR 34 HR 110 SR BP
8965
Sat 87 RA
Dull R base with coarse
crackles
Emergency Department HMO education series
2012
Investigations
The CXR is hellip
ABG on room air
pH 730 CO2 55
O2 70 HCO3 18
What do the blood gases
show
How severe is the
problem
Emergency Department HMO education series
2012
What scoring tools for
pneumonia
SMARTCOP CURB-65 Sepsis guidelines
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
SMARTCOP
SMARTCOP
SMARTCOP
CURB 65
Various website and apps can assist you in
remembering them wwwmdcalccom
Emergency Department HMO education series
2012
Case B4 - Female in her 60rsquos
Sudden onset SOB (present now for 1 hour quite
severe) right sided pleuritic chest pain
Mild fever
Right total knee replacement 3 days ago
persistent leg swelling since yesterday
Non-smoker
No previous cardiorespiratory disease
Emergency Department HMO education series
2012
What is the differential
diagnosis
Emergency Department HMO education series
2012
What is the differential
diagnosis
Most likely
PE
Next likely
Pneumonia
Less likely
Pneumothorax
Arrhythmia
AMI
Emergency Department HMO education series
2012
On examination amp tests
Tachypnoea and some WOB
RR 24 T 376 HR 110 BP 11070
Sats 93 RA
Chest clear with normal percussion and normal breath
sounds
CXR normal
ABG pH 75 CO2 30mmHg p02 62mmHg on RA
Most likely diagnosis
What are Wells criteria
What are Wells criteria
PERC
D-Dimer
What test do you want to do
Emergency Department HMO education series
2012
What can you see
Emergency Department HMO education series
2012
Filling defect R main pulmonary trunk
Emergency Department HMO education series
2012
Emergency Department HMO education series
2012
Case C Man in 60rsquos
Woke this am very SOB and distressed ndash called
ambulance
Progressive SOB over 6 months
Chronic cough
Usually with white sputum
Now worse with no change in sputum colour
No associated fever
SOB in night ndash gets up
Ankles swollen recently
Heavy smoker (35 pack years)
Admission to local hospital 612 ago with chest pains
Emergency Department HMO education series
2012
Differential diagnosis
CCF with acute exacerbation
Chronic obstructive pulmonary disease
(COPD) with acute infective exacerbation
Anaemia
Emergency Department HMO education series
2012
Exam amp investigationshellip
Unwell RR 36 T 368 HR 90 SR BP 180102
Satrsquos 88 RA
Evidence of work of breathing and use of accessory muscles (which are these)
Pursed lip breathing
Prolonged expiration with wheeze
ABG pH 728 pCO2 60 pO2 55 HCO3 26
What do these show
Do you want a CXR
Emergency Department HMO education series
2012
Emergency Department HMO education series
2012
Diagnosis
Acute cardiac failure ndash APO
Most likely cause
Treatment
ECG ndash filed unsigned and
unseen
Emergency Department HMO education series
2012
Diagnosis
Acute cardiac failure ndash APO
Most likely cause
Treatment
Emergency Department HMO education series
2012
Diagnosis - APO
Acute cardiac failure
Treatment
Medications Nitroglycerin SL topical or IV titrated to avoid hypotension Most rapidly
venodilates reduces LV afterload and corrects myocardial ischaemia
Frusemide IV Despite universal use absolute efficacy is unclear
Ventilatory Assistance Non-invasive ventilation (NIV) reduces mortality by 40 particularly with CPAP
and reduces need to intubate
Emergency Department HMO education series
2012
Case C2 - Male in 60rsquos
Progressive SOB over 6 months worse over 24 hours
Orthopnoea Paroxysmal nocturnal dyspnoea (PND) SOA All present to a minor degree over the 6 months but worse for 24 hours
Palpitations (last 24 hours)
Previous AMI 4 years ago pace maker
Ex-smoker Hypertension (HT) diabetes
Emergency Department HMO education series
2012
Examination
Unwell looking with increased work of breathing
RR 26 afeb HR Irreg 130 BP 10070
Sat 90 RA
JVP 5cm
SOA ++
Displaced apex beat no cardiac murmurs 3rd heart sound present
Normal chest expansion but stony dull percussion in the bases (RgtL) bilateral inspiratory crepitations just above the dull areas
ECG ndash what is your diagnosis
Emergency Department HMO education series
2012
Cardiac failure
Emergency Department HMO education series
2012
Case C2 - Summary
Long standing heart failure with an acute
exacerbation due to new onset rapid AF
Treatment of AF amp heart failure
Antithrombotic strategy
Then rate control
Perhaps rhythm control
See review article re AF treatment
To be published early 2013 Australian Rural Doctor
Case D
Mid 60s male
Found SOB ++ in street
Ambulance called
In ED
SOB at rest
Doesnt want help
Funny smell
Further information
Dishevelled
HR 120 reg BP 9560 Sats 94 RA
Vomiting intermittently
What will you do
Further treatment and
investigation
Further history from patient and collateral
sources
Resuscitation
IV access fluids
Bloods ndash FBC UEC CMP Blood gas
pH 71 pCO2 20 pO2 90 HCO3 10 BE -16
Further treatment and
investigation
Further history from patient and collateral
sources
Resuscitation
IV access fluids
Bloods ndash FBC UEC CMP Blood gas
pH 71 pCO2 20 pO2 90 HCO3 10 BE -16
BSL gt30
Further treatment and
investigation
Treatment
IV fluids ndash caution with Na and cerebral oedema
IV insulin
001 ndash 01 unitskghr
aim for BSL 2mmolL drop per hour
Continue until metabolic correction
Monitor and correct K+ other electrolytes
Monitor urine ketones VBGABG
Identify precipitant
Resolution
Wife arrives and is relieved to find husband
Chairman of Rotary Club
UTI developed whilst wife away for weekend
Questions
Summary
Diagnosis of the breathless patient requires you to look for clueshellip The time course of the illness
Associated symptoms
Known diseases or risk factors for disease
Treatment of illnesses supported by evidence for pneumonia asthma PE AF etc
Interpretation of radiology best done with clinical context
Thankyou
Emergency Department HMO education series
2012
What else should I ask
Travel historyhellip
Other important symptoms of respiratory
disease
Cough
Acute
Chronic
Haemoptysis (cancer TB other infections)
Chest Pain
Daytime sleepiness (obstructive sleep apnea)
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Emergency Department HMO education series
2012
Investigations
The CXR is hellip
ABG on room air
pH 730 CO2 55
O2 70 HCO3 18
What do the blood gases
show
How severe is the
problem
Emergency Department HMO education series
2012
What scoring tools for
pneumonia
SMARTCOP CURB-65 Sepsis guidelines
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
SMARTCOP
SMARTCOP
SMARTCOP
CURB 65
Various website and apps can assist you in
remembering them wwwmdcalccom
Emergency Department HMO education series
2012
Case B4 - Female in her 60rsquos
Sudden onset SOB (present now for 1 hour quite
severe) right sided pleuritic chest pain
Mild fever
Right total knee replacement 3 days ago
persistent leg swelling since yesterday
Non-smoker
No previous cardiorespiratory disease
Emergency Department HMO education series
2012
What is the differential
diagnosis
Emergency Department HMO education series
2012
What is the differential
diagnosis
Most likely
PE
Next likely
Pneumonia
Less likely
Pneumothorax
Arrhythmia
AMI
Emergency Department HMO education series
2012
On examination amp tests
Tachypnoea and some WOB
RR 24 T 376 HR 110 BP 11070
Sats 93 RA
Chest clear with normal percussion and normal breath
sounds
CXR normal
ABG pH 75 CO2 30mmHg p02 62mmHg on RA
Most likely diagnosis
What are Wells criteria
What are Wells criteria
PERC
D-Dimer
What test do you want to do
Emergency Department HMO education series
2012
What can you see
Emergency Department HMO education series
2012
Filling defect R main pulmonary trunk
Emergency Department HMO education series
2012
Emergency Department HMO education series
2012
Case C Man in 60rsquos
Woke this am very SOB and distressed ndash called
ambulance
Progressive SOB over 6 months
Chronic cough
Usually with white sputum
Now worse with no change in sputum colour
No associated fever
SOB in night ndash gets up
Ankles swollen recently
Heavy smoker (35 pack years)
Admission to local hospital 612 ago with chest pains
Emergency Department HMO education series
2012
Differential diagnosis
CCF with acute exacerbation
Chronic obstructive pulmonary disease
(COPD) with acute infective exacerbation
Anaemia
Emergency Department HMO education series
2012
Exam amp investigationshellip
Unwell RR 36 T 368 HR 90 SR BP 180102
Satrsquos 88 RA
Evidence of work of breathing and use of accessory muscles (which are these)
Pursed lip breathing
Prolonged expiration with wheeze
ABG pH 728 pCO2 60 pO2 55 HCO3 26
What do these show
Do you want a CXR
Emergency Department HMO education series
2012
Emergency Department HMO education series
2012
Diagnosis
Acute cardiac failure ndash APO
Most likely cause
Treatment
ECG ndash filed unsigned and
unseen
Emergency Department HMO education series
2012
Diagnosis
Acute cardiac failure ndash APO
Most likely cause
Treatment
Emergency Department HMO education series
2012
Diagnosis - APO
Acute cardiac failure
Treatment
Medications Nitroglycerin SL topical or IV titrated to avoid hypotension Most rapidly
venodilates reduces LV afterload and corrects myocardial ischaemia
Frusemide IV Despite universal use absolute efficacy is unclear
Ventilatory Assistance Non-invasive ventilation (NIV) reduces mortality by 40 particularly with CPAP
and reduces need to intubate
Emergency Department HMO education series
2012
Case C2 - Male in 60rsquos
Progressive SOB over 6 months worse over 24 hours
Orthopnoea Paroxysmal nocturnal dyspnoea (PND) SOA All present to a minor degree over the 6 months but worse for 24 hours
Palpitations (last 24 hours)
Previous AMI 4 years ago pace maker
Ex-smoker Hypertension (HT) diabetes
Emergency Department HMO education series
2012
Examination
Unwell looking with increased work of breathing
RR 26 afeb HR Irreg 130 BP 10070
Sat 90 RA
JVP 5cm
SOA ++
Displaced apex beat no cardiac murmurs 3rd heart sound present
Normal chest expansion but stony dull percussion in the bases (RgtL) bilateral inspiratory crepitations just above the dull areas
ECG ndash what is your diagnosis
Emergency Department HMO education series
2012
Cardiac failure
Emergency Department HMO education series
2012
Case C2 - Summary
Long standing heart failure with an acute
exacerbation due to new onset rapid AF
Treatment of AF amp heart failure
Antithrombotic strategy
Then rate control
Perhaps rhythm control
See review article re AF treatment
To be published early 2013 Australian Rural Doctor
Case D
Mid 60s male
Found SOB ++ in street
Ambulance called
In ED
SOB at rest
Doesnt want help
Funny smell
Further information
Dishevelled
HR 120 reg BP 9560 Sats 94 RA
Vomiting intermittently
What will you do
Further treatment and
investigation
Further history from patient and collateral
sources
Resuscitation
IV access fluids
Bloods ndash FBC UEC CMP Blood gas
pH 71 pCO2 20 pO2 90 HCO3 10 BE -16
Further treatment and
investigation
Further history from patient and collateral
sources
Resuscitation
IV access fluids
Bloods ndash FBC UEC CMP Blood gas
pH 71 pCO2 20 pO2 90 HCO3 10 BE -16
BSL gt30
Further treatment and
investigation
Treatment
IV fluids ndash caution with Na and cerebral oedema
IV insulin
001 ndash 01 unitskghr
aim for BSL 2mmolL drop per hour
Continue until metabolic correction
Monitor and correct K+ other electrolytes
Monitor urine ketones VBGABG
Identify precipitant
Resolution
Wife arrives and is relieved to find husband
Chairman of Rotary Club
UTI developed whilst wife away for weekend
Questions
Summary
Diagnosis of the breathless patient requires you to look for clueshellip The time course of the illness
Associated symptoms
Known diseases or risk factors for disease
Treatment of illnesses supported by evidence for pneumonia asthma PE AF etc
Interpretation of radiology best done with clinical context
Thankyou
Emergency Department HMO education series
2012
What else should I ask
Travel historyhellip
Other important symptoms of respiratory
disease
Cough
Acute
Chronic
Haemoptysis (cancer TB other infections)
Chest Pain
Daytime sleepiness (obstructive sleep apnea)
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Emergency Department HMO education series
2012
What scoring tools for
pneumonia
SMARTCOP CURB-65 Sepsis guidelines
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
SMARTCOP
SMARTCOP
SMARTCOP
CURB 65
Various website and apps can assist you in
remembering them wwwmdcalccom
Emergency Department HMO education series
2012
Case B4 - Female in her 60rsquos
Sudden onset SOB (present now for 1 hour quite
severe) right sided pleuritic chest pain
Mild fever
Right total knee replacement 3 days ago
persistent leg swelling since yesterday
Non-smoker
No previous cardiorespiratory disease
Emergency Department HMO education series
2012
What is the differential
diagnosis
Emergency Department HMO education series
2012
What is the differential
diagnosis
Most likely
PE
Next likely
Pneumonia
Less likely
Pneumothorax
Arrhythmia
AMI
Emergency Department HMO education series
2012
On examination amp tests
Tachypnoea and some WOB
RR 24 T 376 HR 110 BP 11070
Sats 93 RA
Chest clear with normal percussion and normal breath
sounds
CXR normal
ABG pH 75 CO2 30mmHg p02 62mmHg on RA
Most likely diagnosis
What are Wells criteria
What are Wells criteria
PERC
D-Dimer
What test do you want to do
Emergency Department HMO education series
2012
What can you see
Emergency Department HMO education series
2012
Filling defect R main pulmonary trunk
Emergency Department HMO education series
2012
Emergency Department HMO education series
2012
Case C Man in 60rsquos
Woke this am very SOB and distressed ndash called
ambulance
Progressive SOB over 6 months
Chronic cough
Usually with white sputum
Now worse with no change in sputum colour
No associated fever
SOB in night ndash gets up
Ankles swollen recently
Heavy smoker (35 pack years)
Admission to local hospital 612 ago with chest pains
Emergency Department HMO education series
2012
Differential diagnosis
CCF with acute exacerbation
Chronic obstructive pulmonary disease
(COPD) with acute infective exacerbation
Anaemia
Emergency Department HMO education series
2012
Exam amp investigationshellip
Unwell RR 36 T 368 HR 90 SR BP 180102
Satrsquos 88 RA
Evidence of work of breathing and use of accessory muscles (which are these)
Pursed lip breathing
Prolonged expiration with wheeze
ABG pH 728 pCO2 60 pO2 55 HCO3 26
What do these show
Do you want a CXR
Emergency Department HMO education series
2012
Emergency Department HMO education series
2012
Diagnosis
Acute cardiac failure ndash APO
Most likely cause
Treatment
ECG ndash filed unsigned and
unseen
Emergency Department HMO education series
2012
Diagnosis
Acute cardiac failure ndash APO
Most likely cause
Treatment
Emergency Department HMO education series
2012
Diagnosis - APO
Acute cardiac failure
Treatment
Medications Nitroglycerin SL topical or IV titrated to avoid hypotension Most rapidly
venodilates reduces LV afterload and corrects myocardial ischaemia
Frusemide IV Despite universal use absolute efficacy is unclear
Ventilatory Assistance Non-invasive ventilation (NIV) reduces mortality by 40 particularly with CPAP
and reduces need to intubate
Emergency Department HMO education series
2012
Case C2 - Male in 60rsquos
Progressive SOB over 6 months worse over 24 hours
Orthopnoea Paroxysmal nocturnal dyspnoea (PND) SOA All present to a minor degree over the 6 months but worse for 24 hours
Palpitations (last 24 hours)
Previous AMI 4 years ago pace maker
Ex-smoker Hypertension (HT) diabetes
Emergency Department HMO education series
2012
Examination
Unwell looking with increased work of breathing
RR 26 afeb HR Irreg 130 BP 10070
Sat 90 RA
JVP 5cm
SOA ++
Displaced apex beat no cardiac murmurs 3rd heart sound present
Normal chest expansion but stony dull percussion in the bases (RgtL) bilateral inspiratory crepitations just above the dull areas
ECG ndash what is your diagnosis
Emergency Department HMO education series
2012
Cardiac failure
Emergency Department HMO education series
2012
Case C2 - Summary
Long standing heart failure with an acute
exacerbation due to new onset rapid AF
Treatment of AF amp heart failure
Antithrombotic strategy
Then rate control
Perhaps rhythm control
See review article re AF treatment
To be published early 2013 Australian Rural Doctor
Case D
Mid 60s male
Found SOB ++ in street
Ambulance called
In ED
SOB at rest
Doesnt want help
Funny smell
Further information
Dishevelled
HR 120 reg BP 9560 Sats 94 RA
Vomiting intermittently
What will you do
Further treatment and
investigation
Further history from patient and collateral
sources
Resuscitation
IV access fluids
Bloods ndash FBC UEC CMP Blood gas
pH 71 pCO2 20 pO2 90 HCO3 10 BE -16
Further treatment and
investigation
Further history from patient and collateral
sources
Resuscitation
IV access fluids
Bloods ndash FBC UEC CMP Blood gas
pH 71 pCO2 20 pO2 90 HCO3 10 BE -16
BSL gt30
Further treatment and
investigation
Treatment
IV fluids ndash caution with Na and cerebral oedema
IV insulin
001 ndash 01 unitskghr
aim for BSL 2mmolL drop per hour
Continue until metabolic correction
Monitor and correct K+ other electrolytes
Monitor urine ketones VBGABG
Identify precipitant
Resolution
Wife arrives and is relieved to find husband
Chairman of Rotary Club
UTI developed whilst wife away for weekend
Questions
Summary
Diagnosis of the breathless patient requires you to look for clueshellip The time course of the illness
Associated symptoms
Known diseases or risk factors for disease
Treatment of illnesses supported by evidence for pneumonia asthma PE AF etc
Interpretation of radiology best done with clinical context
Thankyou
Emergency Department HMO education series
2012
What else should I ask
Travel historyhellip
Other important symptoms of respiratory
disease
Cough
Acute
Chronic
Haemoptysis (cancer TB other infections)
Chest Pain
Daytime sleepiness (obstructive sleep apnea)
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
SMARTCOP
SMARTCOP
SMARTCOP
CURB 65
Various website and apps can assist you in
remembering them wwwmdcalccom
Emergency Department HMO education series
2012
Case B4 - Female in her 60rsquos
Sudden onset SOB (present now for 1 hour quite
severe) right sided pleuritic chest pain
Mild fever
Right total knee replacement 3 days ago
persistent leg swelling since yesterday
Non-smoker
No previous cardiorespiratory disease
Emergency Department HMO education series
2012
What is the differential
diagnosis
Emergency Department HMO education series
2012
What is the differential
diagnosis
Most likely
PE
Next likely
Pneumonia
Less likely
Pneumothorax
Arrhythmia
AMI
Emergency Department HMO education series
2012
On examination amp tests
Tachypnoea and some WOB
RR 24 T 376 HR 110 BP 11070
Sats 93 RA
Chest clear with normal percussion and normal breath
sounds
CXR normal
ABG pH 75 CO2 30mmHg p02 62mmHg on RA
Most likely diagnosis
What are Wells criteria
What are Wells criteria
PERC
D-Dimer
What test do you want to do
Emergency Department HMO education series
2012
What can you see
Emergency Department HMO education series
2012
Filling defect R main pulmonary trunk
Emergency Department HMO education series
2012
Emergency Department HMO education series
2012
Case C Man in 60rsquos
Woke this am very SOB and distressed ndash called
ambulance
Progressive SOB over 6 months
Chronic cough
Usually with white sputum
Now worse with no change in sputum colour
No associated fever
SOB in night ndash gets up
Ankles swollen recently
Heavy smoker (35 pack years)
Admission to local hospital 612 ago with chest pains
Emergency Department HMO education series
2012
Differential diagnosis
CCF with acute exacerbation
Chronic obstructive pulmonary disease
(COPD) with acute infective exacerbation
Anaemia
Emergency Department HMO education series
2012
Exam amp investigationshellip
Unwell RR 36 T 368 HR 90 SR BP 180102
Satrsquos 88 RA
Evidence of work of breathing and use of accessory muscles (which are these)
Pursed lip breathing
Prolonged expiration with wheeze
ABG pH 728 pCO2 60 pO2 55 HCO3 26
What do these show
Do you want a CXR
Emergency Department HMO education series
2012
Emergency Department HMO education series
2012
Diagnosis
Acute cardiac failure ndash APO
Most likely cause
Treatment
ECG ndash filed unsigned and
unseen
Emergency Department HMO education series
2012
Diagnosis
Acute cardiac failure ndash APO
Most likely cause
Treatment
Emergency Department HMO education series
2012
Diagnosis - APO
Acute cardiac failure
Treatment
Medications Nitroglycerin SL topical or IV titrated to avoid hypotension Most rapidly
venodilates reduces LV afterload and corrects myocardial ischaemia
Frusemide IV Despite universal use absolute efficacy is unclear
Ventilatory Assistance Non-invasive ventilation (NIV) reduces mortality by 40 particularly with CPAP
and reduces need to intubate
Emergency Department HMO education series
2012
Case C2 - Male in 60rsquos
Progressive SOB over 6 months worse over 24 hours
Orthopnoea Paroxysmal nocturnal dyspnoea (PND) SOA All present to a minor degree over the 6 months but worse for 24 hours
Palpitations (last 24 hours)
Previous AMI 4 years ago pace maker
Ex-smoker Hypertension (HT) diabetes
Emergency Department HMO education series
2012
Examination
Unwell looking with increased work of breathing
RR 26 afeb HR Irreg 130 BP 10070
Sat 90 RA
JVP 5cm
SOA ++
Displaced apex beat no cardiac murmurs 3rd heart sound present
Normal chest expansion but stony dull percussion in the bases (RgtL) bilateral inspiratory crepitations just above the dull areas
ECG ndash what is your diagnosis
Emergency Department HMO education series
2012
Cardiac failure
Emergency Department HMO education series
2012
Case C2 - Summary
Long standing heart failure with an acute
exacerbation due to new onset rapid AF
Treatment of AF amp heart failure
Antithrombotic strategy
Then rate control
Perhaps rhythm control
See review article re AF treatment
To be published early 2013 Australian Rural Doctor
Case D
Mid 60s male
Found SOB ++ in street
Ambulance called
In ED
SOB at rest
Doesnt want help
Funny smell
Further information
Dishevelled
HR 120 reg BP 9560 Sats 94 RA
Vomiting intermittently
What will you do
Further treatment and
investigation
Further history from patient and collateral
sources
Resuscitation
IV access fluids
Bloods ndash FBC UEC CMP Blood gas
pH 71 pCO2 20 pO2 90 HCO3 10 BE -16
Further treatment and
investigation
Further history from patient and collateral
sources
Resuscitation
IV access fluids
Bloods ndash FBC UEC CMP Blood gas
pH 71 pCO2 20 pO2 90 HCO3 10 BE -16
BSL gt30
Further treatment and
investigation
Treatment
IV fluids ndash caution with Na and cerebral oedema
IV insulin
001 ndash 01 unitskghr
aim for BSL 2mmolL drop per hour
Continue until metabolic correction
Monitor and correct K+ other electrolytes
Monitor urine ketones VBGABG
Identify precipitant
Resolution
Wife arrives and is relieved to find husband
Chairman of Rotary Club
UTI developed whilst wife away for weekend
Questions
Summary
Diagnosis of the breathless patient requires you to look for clueshellip The time course of the illness
Associated symptoms
Known diseases or risk factors for disease
Treatment of illnesses supported by evidence for pneumonia asthma PE AF etc
Interpretation of radiology best done with clinical context
Thankyou
Emergency Department HMO education series
2012
What else should I ask
Travel historyhellip
Other important symptoms of respiratory
disease
Cough
Acute
Chronic
Haemoptysis (cancer TB other infections)
Chest Pain
Daytime sleepiness (obstructive sleep apnea)
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
SMARTCOP
SMARTCOP
CURB 65
Various website and apps can assist you in
remembering them wwwmdcalccom
Emergency Department HMO education series
2012
Case B4 - Female in her 60rsquos
Sudden onset SOB (present now for 1 hour quite
severe) right sided pleuritic chest pain
Mild fever
Right total knee replacement 3 days ago
persistent leg swelling since yesterday
Non-smoker
No previous cardiorespiratory disease
Emergency Department HMO education series
2012
What is the differential
diagnosis
Emergency Department HMO education series
2012
What is the differential
diagnosis
Most likely
PE
Next likely
Pneumonia
Less likely
Pneumothorax
Arrhythmia
AMI
Emergency Department HMO education series
2012
On examination amp tests
Tachypnoea and some WOB
RR 24 T 376 HR 110 BP 11070
Sats 93 RA
Chest clear with normal percussion and normal breath
sounds
CXR normal
ABG pH 75 CO2 30mmHg p02 62mmHg on RA
Most likely diagnosis
What are Wells criteria
What are Wells criteria
PERC
D-Dimer
What test do you want to do
Emergency Department HMO education series
2012
What can you see
Emergency Department HMO education series
2012
Filling defect R main pulmonary trunk
Emergency Department HMO education series
2012
Emergency Department HMO education series
2012
Case C Man in 60rsquos
Woke this am very SOB and distressed ndash called
ambulance
Progressive SOB over 6 months
Chronic cough
Usually with white sputum
Now worse with no change in sputum colour
No associated fever
SOB in night ndash gets up
Ankles swollen recently
Heavy smoker (35 pack years)
Admission to local hospital 612 ago with chest pains
Emergency Department HMO education series
2012
Differential diagnosis
CCF with acute exacerbation
Chronic obstructive pulmonary disease
(COPD) with acute infective exacerbation
Anaemia
Emergency Department HMO education series
2012
Exam amp investigationshellip
Unwell RR 36 T 368 HR 90 SR BP 180102
Satrsquos 88 RA
Evidence of work of breathing and use of accessory muscles (which are these)
Pursed lip breathing
Prolonged expiration with wheeze
ABG pH 728 pCO2 60 pO2 55 HCO3 26
What do these show
Do you want a CXR
Emergency Department HMO education series
2012
Emergency Department HMO education series
2012
Diagnosis
Acute cardiac failure ndash APO
Most likely cause
Treatment
ECG ndash filed unsigned and
unseen
Emergency Department HMO education series
2012
Diagnosis
Acute cardiac failure ndash APO
Most likely cause
Treatment
Emergency Department HMO education series
2012
Diagnosis - APO
Acute cardiac failure
Treatment
Medications Nitroglycerin SL topical or IV titrated to avoid hypotension Most rapidly
venodilates reduces LV afterload and corrects myocardial ischaemia
Frusemide IV Despite universal use absolute efficacy is unclear
Ventilatory Assistance Non-invasive ventilation (NIV) reduces mortality by 40 particularly with CPAP
and reduces need to intubate
Emergency Department HMO education series
2012
Case C2 - Male in 60rsquos
Progressive SOB over 6 months worse over 24 hours
Orthopnoea Paroxysmal nocturnal dyspnoea (PND) SOA All present to a minor degree over the 6 months but worse for 24 hours
Palpitations (last 24 hours)
Previous AMI 4 years ago pace maker
Ex-smoker Hypertension (HT) diabetes
Emergency Department HMO education series
2012
Examination
Unwell looking with increased work of breathing
RR 26 afeb HR Irreg 130 BP 10070
Sat 90 RA
JVP 5cm
SOA ++
Displaced apex beat no cardiac murmurs 3rd heart sound present
Normal chest expansion but stony dull percussion in the bases (RgtL) bilateral inspiratory crepitations just above the dull areas
ECG ndash what is your diagnosis
Emergency Department HMO education series
2012
Cardiac failure
Emergency Department HMO education series
2012
Case C2 - Summary
Long standing heart failure with an acute
exacerbation due to new onset rapid AF
Treatment of AF amp heart failure
Antithrombotic strategy
Then rate control
Perhaps rhythm control
See review article re AF treatment
To be published early 2013 Australian Rural Doctor
Case D
Mid 60s male
Found SOB ++ in street
Ambulance called
In ED
SOB at rest
Doesnt want help
Funny smell
Further information
Dishevelled
HR 120 reg BP 9560 Sats 94 RA
Vomiting intermittently
What will you do
Further treatment and
investigation
Further history from patient and collateral
sources
Resuscitation
IV access fluids
Bloods ndash FBC UEC CMP Blood gas
pH 71 pCO2 20 pO2 90 HCO3 10 BE -16
Further treatment and
investigation
Further history from patient and collateral
sources
Resuscitation
IV access fluids
Bloods ndash FBC UEC CMP Blood gas
pH 71 pCO2 20 pO2 90 HCO3 10 BE -16
BSL gt30
Further treatment and
investigation
Treatment
IV fluids ndash caution with Na and cerebral oedema
IV insulin
001 ndash 01 unitskghr
aim for BSL 2mmolL drop per hour
Continue until metabolic correction
Monitor and correct K+ other electrolytes
Monitor urine ketones VBGABG
Identify precipitant
Resolution
Wife arrives and is relieved to find husband
Chairman of Rotary Club
UTI developed whilst wife away for weekend
Questions
Summary
Diagnosis of the breathless patient requires you to look for clueshellip The time course of the illness
Associated symptoms
Known diseases or risk factors for disease
Treatment of illnesses supported by evidence for pneumonia asthma PE AF etc
Interpretation of radiology best done with clinical context
Thankyou
Emergency Department HMO education series
2012
What else should I ask
Travel historyhellip
Other important symptoms of respiratory
disease
Cough
Acute
Chronic
Haemoptysis (cancer TB other infections)
Chest Pain
Daytime sleepiness (obstructive sleep apnea)
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
SMARTCOP
CURB 65
Various website and apps can assist you in
remembering them wwwmdcalccom
Emergency Department HMO education series
2012
Case B4 - Female in her 60rsquos
Sudden onset SOB (present now for 1 hour quite
severe) right sided pleuritic chest pain
Mild fever
Right total knee replacement 3 days ago
persistent leg swelling since yesterday
Non-smoker
No previous cardiorespiratory disease
Emergency Department HMO education series
2012
What is the differential
diagnosis
Emergency Department HMO education series
2012
What is the differential
diagnosis
Most likely
PE
Next likely
Pneumonia
Less likely
Pneumothorax
Arrhythmia
AMI
Emergency Department HMO education series
2012
On examination amp tests
Tachypnoea and some WOB
RR 24 T 376 HR 110 BP 11070
Sats 93 RA
Chest clear with normal percussion and normal breath
sounds
CXR normal
ABG pH 75 CO2 30mmHg p02 62mmHg on RA
Most likely diagnosis
What are Wells criteria
What are Wells criteria
PERC
D-Dimer
What test do you want to do
Emergency Department HMO education series
2012
What can you see
Emergency Department HMO education series
2012
Filling defect R main pulmonary trunk
Emergency Department HMO education series
2012
Emergency Department HMO education series
2012
Case C Man in 60rsquos
Woke this am very SOB and distressed ndash called
ambulance
Progressive SOB over 6 months
Chronic cough
Usually with white sputum
Now worse with no change in sputum colour
No associated fever
SOB in night ndash gets up
Ankles swollen recently
Heavy smoker (35 pack years)
Admission to local hospital 612 ago with chest pains
Emergency Department HMO education series
2012
Differential diagnosis
CCF with acute exacerbation
Chronic obstructive pulmonary disease
(COPD) with acute infective exacerbation
Anaemia
Emergency Department HMO education series
2012
Exam amp investigationshellip
Unwell RR 36 T 368 HR 90 SR BP 180102
Satrsquos 88 RA
Evidence of work of breathing and use of accessory muscles (which are these)
Pursed lip breathing
Prolonged expiration with wheeze
ABG pH 728 pCO2 60 pO2 55 HCO3 26
What do these show
Do you want a CXR
Emergency Department HMO education series
2012
Emergency Department HMO education series
2012
Diagnosis
Acute cardiac failure ndash APO
Most likely cause
Treatment
ECG ndash filed unsigned and
unseen
Emergency Department HMO education series
2012
Diagnosis
Acute cardiac failure ndash APO
Most likely cause
Treatment
Emergency Department HMO education series
2012
Diagnosis - APO
Acute cardiac failure
Treatment
Medications Nitroglycerin SL topical or IV titrated to avoid hypotension Most rapidly
venodilates reduces LV afterload and corrects myocardial ischaemia
Frusemide IV Despite universal use absolute efficacy is unclear
Ventilatory Assistance Non-invasive ventilation (NIV) reduces mortality by 40 particularly with CPAP
and reduces need to intubate
Emergency Department HMO education series
2012
Case C2 - Male in 60rsquos
Progressive SOB over 6 months worse over 24 hours
Orthopnoea Paroxysmal nocturnal dyspnoea (PND) SOA All present to a minor degree over the 6 months but worse for 24 hours
Palpitations (last 24 hours)
Previous AMI 4 years ago pace maker
Ex-smoker Hypertension (HT) diabetes
Emergency Department HMO education series
2012
Examination
Unwell looking with increased work of breathing
RR 26 afeb HR Irreg 130 BP 10070
Sat 90 RA
JVP 5cm
SOA ++
Displaced apex beat no cardiac murmurs 3rd heart sound present
Normal chest expansion but stony dull percussion in the bases (RgtL) bilateral inspiratory crepitations just above the dull areas
ECG ndash what is your diagnosis
Emergency Department HMO education series
2012
Cardiac failure
Emergency Department HMO education series
2012
Case C2 - Summary
Long standing heart failure with an acute
exacerbation due to new onset rapid AF
Treatment of AF amp heart failure
Antithrombotic strategy
Then rate control
Perhaps rhythm control
See review article re AF treatment
To be published early 2013 Australian Rural Doctor
Case D
Mid 60s male
Found SOB ++ in street
Ambulance called
In ED
SOB at rest
Doesnt want help
Funny smell
Further information
Dishevelled
HR 120 reg BP 9560 Sats 94 RA
Vomiting intermittently
What will you do
Further treatment and
investigation
Further history from patient and collateral
sources
Resuscitation
IV access fluids
Bloods ndash FBC UEC CMP Blood gas
pH 71 pCO2 20 pO2 90 HCO3 10 BE -16
Further treatment and
investigation
Further history from patient and collateral
sources
Resuscitation
IV access fluids
Bloods ndash FBC UEC CMP Blood gas
pH 71 pCO2 20 pO2 90 HCO3 10 BE -16
BSL gt30
Further treatment and
investigation
Treatment
IV fluids ndash caution with Na and cerebral oedema
IV insulin
001 ndash 01 unitskghr
aim for BSL 2mmolL drop per hour
Continue until metabolic correction
Monitor and correct K+ other electrolytes
Monitor urine ketones VBGABG
Identify precipitant
Resolution
Wife arrives and is relieved to find husband
Chairman of Rotary Club
UTI developed whilst wife away for weekend
Questions
Summary
Diagnosis of the breathless patient requires you to look for clueshellip The time course of the illness
Associated symptoms
Known diseases or risk factors for disease
Treatment of illnesses supported by evidence for pneumonia asthma PE AF etc
Interpretation of radiology best done with clinical context
Thankyou
Emergency Department HMO education series
2012
What else should I ask
Travel historyhellip
Other important symptoms of respiratory
disease
Cough
Acute
Chronic
Haemoptysis (cancer TB other infections)
Chest Pain
Daytime sleepiness (obstructive sleep apnea)
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
CURB 65
Various website and apps can assist you in
remembering them wwwmdcalccom
Emergency Department HMO education series
2012
Case B4 - Female in her 60rsquos
Sudden onset SOB (present now for 1 hour quite
severe) right sided pleuritic chest pain
Mild fever
Right total knee replacement 3 days ago
persistent leg swelling since yesterday
Non-smoker
No previous cardiorespiratory disease
Emergency Department HMO education series
2012
What is the differential
diagnosis
Emergency Department HMO education series
2012
What is the differential
diagnosis
Most likely
PE
Next likely
Pneumonia
Less likely
Pneumothorax
Arrhythmia
AMI
Emergency Department HMO education series
2012
On examination amp tests
Tachypnoea and some WOB
RR 24 T 376 HR 110 BP 11070
Sats 93 RA
Chest clear with normal percussion and normal breath
sounds
CXR normal
ABG pH 75 CO2 30mmHg p02 62mmHg on RA
Most likely diagnosis
What are Wells criteria
What are Wells criteria
PERC
D-Dimer
What test do you want to do
Emergency Department HMO education series
2012
What can you see
Emergency Department HMO education series
2012
Filling defect R main pulmonary trunk
Emergency Department HMO education series
2012
Emergency Department HMO education series
2012
Case C Man in 60rsquos
Woke this am very SOB and distressed ndash called
ambulance
Progressive SOB over 6 months
Chronic cough
Usually with white sputum
Now worse with no change in sputum colour
No associated fever
SOB in night ndash gets up
Ankles swollen recently
Heavy smoker (35 pack years)
Admission to local hospital 612 ago with chest pains
Emergency Department HMO education series
2012
Differential diagnosis
CCF with acute exacerbation
Chronic obstructive pulmonary disease
(COPD) with acute infective exacerbation
Anaemia
Emergency Department HMO education series
2012
Exam amp investigationshellip
Unwell RR 36 T 368 HR 90 SR BP 180102
Satrsquos 88 RA
Evidence of work of breathing and use of accessory muscles (which are these)
Pursed lip breathing
Prolonged expiration with wheeze
ABG pH 728 pCO2 60 pO2 55 HCO3 26
What do these show
Do you want a CXR
Emergency Department HMO education series
2012
Emergency Department HMO education series
2012
Diagnosis
Acute cardiac failure ndash APO
Most likely cause
Treatment
ECG ndash filed unsigned and
unseen
Emergency Department HMO education series
2012
Diagnosis
Acute cardiac failure ndash APO
Most likely cause
Treatment
Emergency Department HMO education series
2012
Diagnosis - APO
Acute cardiac failure
Treatment
Medications Nitroglycerin SL topical or IV titrated to avoid hypotension Most rapidly
venodilates reduces LV afterload and corrects myocardial ischaemia
Frusemide IV Despite universal use absolute efficacy is unclear
Ventilatory Assistance Non-invasive ventilation (NIV) reduces mortality by 40 particularly with CPAP
and reduces need to intubate
Emergency Department HMO education series
2012
Case C2 - Male in 60rsquos
Progressive SOB over 6 months worse over 24 hours
Orthopnoea Paroxysmal nocturnal dyspnoea (PND) SOA All present to a minor degree over the 6 months but worse for 24 hours
Palpitations (last 24 hours)
Previous AMI 4 years ago pace maker
Ex-smoker Hypertension (HT) diabetes
Emergency Department HMO education series
2012
Examination
Unwell looking with increased work of breathing
RR 26 afeb HR Irreg 130 BP 10070
Sat 90 RA
JVP 5cm
SOA ++
Displaced apex beat no cardiac murmurs 3rd heart sound present
Normal chest expansion but stony dull percussion in the bases (RgtL) bilateral inspiratory crepitations just above the dull areas
ECG ndash what is your diagnosis
Emergency Department HMO education series
2012
Cardiac failure
Emergency Department HMO education series
2012
Case C2 - Summary
Long standing heart failure with an acute
exacerbation due to new onset rapid AF
Treatment of AF amp heart failure
Antithrombotic strategy
Then rate control
Perhaps rhythm control
See review article re AF treatment
To be published early 2013 Australian Rural Doctor
Case D
Mid 60s male
Found SOB ++ in street
Ambulance called
In ED
SOB at rest
Doesnt want help
Funny smell
Further information
Dishevelled
HR 120 reg BP 9560 Sats 94 RA
Vomiting intermittently
What will you do
Further treatment and
investigation
Further history from patient and collateral
sources
Resuscitation
IV access fluids
Bloods ndash FBC UEC CMP Blood gas
pH 71 pCO2 20 pO2 90 HCO3 10 BE -16
Further treatment and
investigation
Further history from patient and collateral
sources
Resuscitation
IV access fluids
Bloods ndash FBC UEC CMP Blood gas
pH 71 pCO2 20 pO2 90 HCO3 10 BE -16
BSL gt30
Further treatment and
investigation
Treatment
IV fluids ndash caution with Na and cerebral oedema
IV insulin
001 ndash 01 unitskghr
aim for BSL 2mmolL drop per hour
Continue until metabolic correction
Monitor and correct K+ other electrolytes
Monitor urine ketones VBGABG
Identify precipitant
Resolution
Wife arrives and is relieved to find husband
Chairman of Rotary Club
UTI developed whilst wife away for weekend
Questions
Summary
Diagnosis of the breathless patient requires you to look for clueshellip The time course of the illness
Associated symptoms
Known diseases or risk factors for disease
Treatment of illnesses supported by evidence for pneumonia asthma PE AF etc
Interpretation of radiology best done with clinical context
Thankyou
Emergency Department HMO education series
2012
What else should I ask
Travel historyhellip
Other important symptoms of respiratory
disease
Cough
Acute
Chronic
Haemoptysis (cancer TB other infections)
Chest Pain
Daytime sleepiness (obstructive sleep apnea)
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Emergency Department HMO education series
2012
Case B4 - Female in her 60rsquos
Sudden onset SOB (present now for 1 hour quite
severe) right sided pleuritic chest pain
Mild fever
Right total knee replacement 3 days ago
persistent leg swelling since yesterday
Non-smoker
No previous cardiorespiratory disease
Emergency Department HMO education series
2012
What is the differential
diagnosis
Emergency Department HMO education series
2012
What is the differential
diagnosis
Most likely
PE
Next likely
Pneumonia
Less likely
Pneumothorax
Arrhythmia
AMI
Emergency Department HMO education series
2012
On examination amp tests
Tachypnoea and some WOB
RR 24 T 376 HR 110 BP 11070
Sats 93 RA
Chest clear with normal percussion and normal breath
sounds
CXR normal
ABG pH 75 CO2 30mmHg p02 62mmHg on RA
Most likely diagnosis
What are Wells criteria
What are Wells criteria
PERC
D-Dimer
What test do you want to do
Emergency Department HMO education series
2012
What can you see
Emergency Department HMO education series
2012
Filling defect R main pulmonary trunk
Emergency Department HMO education series
2012
Emergency Department HMO education series
2012
Case C Man in 60rsquos
Woke this am very SOB and distressed ndash called
ambulance
Progressive SOB over 6 months
Chronic cough
Usually with white sputum
Now worse with no change in sputum colour
No associated fever
SOB in night ndash gets up
Ankles swollen recently
Heavy smoker (35 pack years)
Admission to local hospital 612 ago with chest pains
Emergency Department HMO education series
2012
Differential diagnosis
CCF with acute exacerbation
Chronic obstructive pulmonary disease
(COPD) with acute infective exacerbation
Anaemia
Emergency Department HMO education series
2012
Exam amp investigationshellip
Unwell RR 36 T 368 HR 90 SR BP 180102
Satrsquos 88 RA
Evidence of work of breathing and use of accessory muscles (which are these)
Pursed lip breathing
Prolonged expiration with wheeze
ABG pH 728 pCO2 60 pO2 55 HCO3 26
What do these show
Do you want a CXR
Emergency Department HMO education series
2012
Emergency Department HMO education series
2012
Diagnosis
Acute cardiac failure ndash APO
Most likely cause
Treatment
ECG ndash filed unsigned and
unseen
Emergency Department HMO education series
2012
Diagnosis
Acute cardiac failure ndash APO
Most likely cause
Treatment
Emergency Department HMO education series
2012
Diagnosis - APO
Acute cardiac failure
Treatment
Medications Nitroglycerin SL topical or IV titrated to avoid hypotension Most rapidly
venodilates reduces LV afterload and corrects myocardial ischaemia
Frusemide IV Despite universal use absolute efficacy is unclear
Ventilatory Assistance Non-invasive ventilation (NIV) reduces mortality by 40 particularly with CPAP
and reduces need to intubate
Emergency Department HMO education series
2012
Case C2 - Male in 60rsquos
Progressive SOB over 6 months worse over 24 hours
Orthopnoea Paroxysmal nocturnal dyspnoea (PND) SOA All present to a minor degree over the 6 months but worse for 24 hours
Palpitations (last 24 hours)
Previous AMI 4 years ago pace maker
Ex-smoker Hypertension (HT) diabetes
Emergency Department HMO education series
2012
Examination
Unwell looking with increased work of breathing
RR 26 afeb HR Irreg 130 BP 10070
Sat 90 RA
JVP 5cm
SOA ++
Displaced apex beat no cardiac murmurs 3rd heart sound present
Normal chest expansion but stony dull percussion in the bases (RgtL) bilateral inspiratory crepitations just above the dull areas
ECG ndash what is your diagnosis
Emergency Department HMO education series
2012
Cardiac failure
Emergency Department HMO education series
2012
Case C2 - Summary
Long standing heart failure with an acute
exacerbation due to new onset rapid AF
Treatment of AF amp heart failure
Antithrombotic strategy
Then rate control
Perhaps rhythm control
See review article re AF treatment
To be published early 2013 Australian Rural Doctor
Case D
Mid 60s male
Found SOB ++ in street
Ambulance called
In ED
SOB at rest
Doesnt want help
Funny smell
Further information
Dishevelled
HR 120 reg BP 9560 Sats 94 RA
Vomiting intermittently
What will you do
Further treatment and
investigation
Further history from patient and collateral
sources
Resuscitation
IV access fluids
Bloods ndash FBC UEC CMP Blood gas
pH 71 pCO2 20 pO2 90 HCO3 10 BE -16
Further treatment and
investigation
Further history from patient and collateral
sources
Resuscitation
IV access fluids
Bloods ndash FBC UEC CMP Blood gas
pH 71 pCO2 20 pO2 90 HCO3 10 BE -16
BSL gt30
Further treatment and
investigation
Treatment
IV fluids ndash caution with Na and cerebral oedema
IV insulin
001 ndash 01 unitskghr
aim for BSL 2mmolL drop per hour
Continue until metabolic correction
Monitor and correct K+ other electrolytes
Monitor urine ketones VBGABG
Identify precipitant
Resolution
Wife arrives and is relieved to find husband
Chairman of Rotary Club
UTI developed whilst wife away for weekend
Questions
Summary
Diagnosis of the breathless patient requires you to look for clueshellip The time course of the illness
Associated symptoms
Known diseases or risk factors for disease
Treatment of illnesses supported by evidence for pneumonia asthma PE AF etc
Interpretation of radiology best done with clinical context
Thankyou
Emergency Department HMO education series
2012
What else should I ask
Travel historyhellip
Other important symptoms of respiratory
disease
Cough
Acute
Chronic
Haemoptysis (cancer TB other infections)
Chest Pain
Daytime sleepiness (obstructive sleep apnea)
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Emergency Department HMO education series
2012
What is the differential
diagnosis
Emergency Department HMO education series
2012
What is the differential
diagnosis
Most likely
PE
Next likely
Pneumonia
Less likely
Pneumothorax
Arrhythmia
AMI
Emergency Department HMO education series
2012
On examination amp tests
Tachypnoea and some WOB
RR 24 T 376 HR 110 BP 11070
Sats 93 RA
Chest clear with normal percussion and normal breath
sounds
CXR normal
ABG pH 75 CO2 30mmHg p02 62mmHg on RA
Most likely diagnosis
What are Wells criteria
What are Wells criteria
PERC
D-Dimer
What test do you want to do
Emergency Department HMO education series
2012
What can you see
Emergency Department HMO education series
2012
Filling defect R main pulmonary trunk
Emergency Department HMO education series
2012
Emergency Department HMO education series
2012
Case C Man in 60rsquos
Woke this am very SOB and distressed ndash called
ambulance
Progressive SOB over 6 months
Chronic cough
Usually with white sputum
Now worse with no change in sputum colour
No associated fever
SOB in night ndash gets up
Ankles swollen recently
Heavy smoker (35 pack years)
Admission to local hospital 612 ago with chest pains
Emergency Department HMO education series
2012
Differential diagnosis
CCF with acute exacerbation
Chronic obstructive pulmonary disease
(COPD) with acute infective exacerbation
Anaemia
Emergency Department HMO education series
2012
Exam amp investigationshellip
Unwell RR 36 T 368 HR 90 SR BP 180102
Satrsquos 88 RA
Evidence of work of breathing and use of accessory muscles (which are these)
Pursed lip breathing
Prolonged expiration with wheeze
ABG pH 728 pCO2 60 pO2 55 HCO3 26
What do these show
Do you want a CXR
Emergency Department HMO education series
2012
Emergency Department HMO education series
2012
Diagnosis
Acute cardiac failure ndash APO
Most likely cause
Treatment
ECG ndash filed unsigned and
unseen
Emergency Department HMO education series
2012
Diagnosis
Acute cardiac failure ndash APO
Most likely cause
Treatment
Emergency Department HMO education series
2012
Diagnosis - APO
Acute cardiac failure
Treatment
Medications Nitroglycerin SL topical or IV titrated to avoid hypotension Most rapidly
venodilates reduces LV afterload and corrects myocardial ischaemia
Frusemide IV Despite universal use absolute efficacy is unclear
Ventilatory Assistance Non-invasive ventilation (NIV) reduces mortality by 40 particularly with CPAP
and reduces need to intubate
Emergency Department HMO education series
2012
Case C2 - Male in 60rsquos
Progressive SOB over 6 months worse over 24 hours
Orthopnoea Paroxysmal nocturnal dyspnoea (PND) SOA All present to a minor degree over the 6 months but worse for 24 hours
Palpitations (last 24 hours)
Previous AMI 4 years ago pace maker
Ex-smoker Hypertension (HT) diabetes
Emergency Department HMO education series
2012
Examination
Unwell looking with increased work of breathing
RR 26 afeb HR Irreg 130 BP 10070
Sat 90 RA
JVP 5cm
SOA ++
Displaced apex beat no cardiac murmurs 3rd heart sound present
Normal chest expansion but stony dull percussion in the bases (RgtL) bilateral inspiratory crepitations just above the dull areas
ECG ndash what is your diagnosis
Emergency Department HMO education series
2012
Cardiac failure
Emergency Department HMO education series
2012
Case C2 - Summary
Long standing heart failure with an acute
exacerbation due to new onset rapid AF
Treatment of AF amp heart failure
Antithrombotic strategy
Then rate control
Perhaps rhythm control
See review article re AF treatment
To be published early 2013 Australian Rural Doctor
Case D
Mid 60s male
Found SOB ++ in street
Ambulance called
In ED
SOB at rest
Doesnt want help
Funny smell
Further information
Dishevelled
HR 120 reg BP 9560 Sats 94 RA
Vomiting intermittently
What will you do
Further treatment and
investigation
Further history from patient and collateral
sources
Resuscitation
IV access fluids
Bloods ndash FBC UEC CMP Blood gas
pH 71 pCO2 20 pO2 90 HCO3 10 BE -16
Further treatment and
investigation
Further history from patient and collateral
sources
Resuscitation
IV access fluids
Bloods ndash FBC UEC CMP Blood gas
pH 71 pCO2 20 pO2 90 HCO3 10 BE -16
BSL gt30
Further treatment and
investigation
Treatment
IV fluids ndash caution with Na and cerebral oedema
IV insulin
001 ndash 01 unitskghr
aim for BSL 2mmolL drop per hour
Continue until metabolic correction
Monitor and correct K+ other electrolytes
Monitor urine ketones VBGABG
Identify precipitant
Resolution
Wife arrives and is relieved to find husband
Chairman of Rotary Club
UTI developed whilst wife away for weekend
Questions
Summary
Diagnosis of the breathless patient requires you to look for clueshellip The time course of the illness
Associated symptoms
Known diseases or risk factors for disease
Treatment of illnesses supported by evidence for pneumonia asthma PE AF etc
Interpretation of radiology best done with clinical context
Thankyou
Emergency Department HMO education series
2012
What else should I ask
Travel historyhellip
Other important symptoms of respiratory
disease
Cough
Acute
Chronic
Haemoptysis (cancer TB other infections)
Chest Pain
Daytime sleepiness (obstructive sleep apnea)
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Emergency Department HMO education series
2012
What is the differential
diagnosis
Most likely
PE
Next likely
Pneumonia
Less likely
Pneumothorax
Arrhythmia
AMI
Emergency Department HMO education series
2012
On examination amp tests
Tachypnoea and some WOB
RR 24 T 376 HR 110 BP 11070
Sats 93 RA
Chest clear with normal percussion and normal breath
sounds
CXR normal
ABG pH 75 CO2 30mmHg p02 62mmHg on RA
Most likely diagnosis
What are Wells criteria
What are Wells criteria
PERC
D-Dimer
What test do you want to do
Emergency Department HMO education series
2012
What can you see
Emergency Department HMO education series
2012
Filling defect R main pulmonary trunk
Emergency Department HMO education series
2012
Emergency Department HMO education series
2012
Case C Man in 60rsquos
Woke this am very SOB and distressed ndash called
ambulance
Progressive SOB over 6 months
Chronic cough
Usually with white sputum
Now worse with no change in sputum colour
No associated fever
SOB in night ndash gets up
Ankles swollen recently
Heavy smoker (35 pack years)
Admission to local hospital 612 ago with chest pains
Emergency Department HMO education series
2012
Differential diagnosis
CCF with acute exacerbation
Chronic obstructive pulmonary disease
(COPD) with acute infective exacerbation
Anaemia
Emergency Department HMO education series
2012
Exam amp investigationshellip
Unwell RR 36 T 368 HR 90 SR BP 180102
Satrsquos 88 RA
Evidence of work of breathing and use of accessory muscles (which are these)
Pursed lip breathing
Prolonged expiration with wheeze
ABG pH 728 pCO2 60 pO2 55 HCO3 26
What do these show
Do you want a CXR
Emergency Department HMO education series
2012
Emergency Department HMO education series
2012
Diagnosis
Acute cardiac failure ndash APO
Most likely cause
Treatment
ECG ndash filed unsigned and
unseen
Emergency Department HMO education series
2012
Diagnosis
Acute cardiac failure ndash APO
Most likely cause
Treatment
Emergency Department HMO education series
2012
Diagnosis - APO
Acute cardiac failure
Treatment
Medications Nitroglycerin SL topical or IV titrated to avoid hypotension Most rapidly
venodilates reduces LV afterload and corrects myocardial ischaemia
Frusemide IV Despite universal use absolute efficacy is unclear
Ventilatory Assistance Non-invasive ventilation (NIV) reduces mortality by 40 particularly with CPAP
and reduces need to intubate
Emergency Department HMO education series
2012
Case C2 - Male in 60rsquos
Progressive SOB over 6 months worse over 24 hours
Orthopnoea Paroxysmal nocturnal dyspnoea (PND) SOA All present to a minor degree over the 6 months but worse for 24 hours
Palpitations (last 24 hours)
Previous AMI 4 years ago pace maker
Ex-smoker Hypertension (HT) diabetes
Emergency Department HMO education series
2012
Examination
Unwell looking with increased work of breathing
RR 26 afeb HR Irreg 130 BP 10070
Sat 90 RA
JVP 5cm
SOA ++
Displaced apex beat no cardiac murmurs 3rd heart sound present
Normal chest expansion but stony dull percussion in the bases (RgtL) bilateral inspiratory crepitations just above the dull areas
ECG ndash what is your diagnosis
Emergency Department HMO education series
2012
Cardiac failure
Emergency Department HMO education series
2012
Case C2 - Summary
Long standing heart failure with an acute
exacerbation due to new onset rapid AF
Treatment of AF amp heart failure
Antithrombotic strategy
Then rate control
Perhaps rhythm control
See review article re AF treatment
To be published early 2013 Australian Rural Doctor
Case D
Mid 60s male
Found SOB ++ in street
Ambulance called
In ED
SOB at rest
Doesnt want help
Funny smell
Further information
Dishevelled
HR 120 reg BP 9560 Sats 94 RA
Vomiting intermittently
What will you do
Further treatment and
investigation
Further history from patient and collateral
sources
Resuscitation
IV access fluids
Bloods ndash FBC UEC CMP Blood gas
pH 71 pCO2 20 pO2 90 HCO3 10 BE -16
Further treatment and
investigation
Further history from patient and collateral
sources
Resuscitation
IV access fluids
Bloods ndash FBC UEC CMP Blood gas
pH 71 pCO2 20 pO2 90 HCO3 10 BE -16
BSL gt30
Further treatment and
investigation
Treatment
IV fluids ndash caution with Na and cerebral oedema
IV insulin
001 ndash 01 unitskghr
aim for BSL 2mmolL drop per hour
Continue until metabolic correction
Monitor and correct K+ other electrolytes
Monitor urine ketones VBGABG
Identify precipitant
Resolution
Wife arrives and is relieved to find husband
Chairman of Rotary Club
UTI developed whilst wife away for weekend
Questions
Summary
Diagnosis of the breathless patient requires you to look for clueshellip The time course of the illness
Associated symptoms
Known diseases or risk factors for disease
Treatment of illnesses supported by evidence for pneumonia asthma PE AF etc
Interpretation of radiology best done with clinical context
Thankyou
Emergency Department HMO education series
2012
What else should I ask
Travel historyhellip
Other important symptoms of respiratory
disease
Cough
Acute
Chronic
Haemoptysis (cancer TB other infections)
Chest Pain
Daytime sleepiness (obstructive sleep apnea)
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Emergency Department HMO education series
2012
On examination amp tests
Tachypnoea and some WOB
RR 24 T 376 HR 110 BP 11070
Sats 93 RA
Chest clear with normal percussion and normal breath
sounds
CXR normal
ABG pH 75 CO2 30mmHg p02 62mmHg on RA
Most likely diagnosis
What are Wells criteria
What are Wells criteria
PERC
D-Dimer
What test do you want to do
Emergency Department HMO education series
2012
What can you see
Emergency Department HMO education series
2012
Filling defect R main pulmonary trunk
Emergency Department HMO education series
2012
Emergency Department HMO education series
2012
Case C Man in 60rsquos
Woke this am very SOB and distressed ndash called
ambulance
Progressive SOB over 6 months
Chronic cough
Usually with white sputum
Now worse with no change in sputum colour
No associated fever
SOB in night ndash gets up
Ankles swollen recently
Heavy smoker (35 pack years)
Admission to local hospital 612 ago with chest pains
Emergency Department HMO education series
2012
Differential diagnosis
CCF with acute exacerbation
Chronic obstructive pulmonary disease
(COPD) with acute infective exacerbation
Anaemia
Emergency Department HMO education series
2012
Exam amp investigationshellip
Unwell RR 36 T 368 HR 90 SR BP 180102
Satrsquos 88 RA
Evidence of work of breathing and use of accessory muscles (which are these)
Pursed lip breathing
Prolonged expiration with wheeze
ABG pH 728 pCO2 60 pO2 55 HCO3 26
What do these show
Do you want a CXR
Emergency Department HMO education series
2012
Emergency Department HMO education series
2012
Diagnosis
Acute cardiac failure ndash APO
Most likely cause
Treatment
ECG ndash filed unsigned and
unseen
Emergency Department HMO education series
2012
Diagnosis
Acute cardiac failure ndash APO
Most likely cause
Treatment
Emergency Department HMO education series
2012
Diagnosis - APO
Acute cardiac failure
Treatment
Medications Nitroglycerin SL topical or IV titrated to avoid hypotension Most rapidly
venodilates reduces LV afterload and corrects myocardial ischaemia
Frusemide IV Despite universal use absolute efficacy is unclear
Ventilatory Assistance Non-invasive ventilation (NIV) reduces mortality by 40 particularly with CPAP
and reduces need to intubate
Emergency Department HMO education series
2012
Case C2 - Male in 60rsquos
Progressive SOB over 6 months worse over 24 hours
Orthopnoea Paroxysmal nocturnal dyspnoea (PND) SOA All present to a minor degree over the 6 months but worse for 24 hours
Palpitations (last 24 hours)
Previous AMI 4 years ago pace maker
Ex-smoker Hypertension (HT) diabetes
Emergency Department HMO education series
2012
Examination
Unwell looking with increased work of breathing
RR 26 afeb HR Irreg 130 BP 10070
Sat 90 RA
JVP 5cm
SOA ++
Displaced apex beat no cardiac murmurs 3rd heart sound present
Normal chest expansion but stony dull percussion in the bases (RgtL) bilateral inspiratory crepitations just above the dull areas
ECG ndash what is your diagnosis
Emergency Department HMO education series
2012
Cardiac failure
Emergency Department HMO education series
2012
Case C2 - Summary
Long standing heart failure with an acute
exacerbation due to new onset rapid AF
Treatment of AF amp heart failure
Antithrombotic strategy
Then rate control
Perhaps rhythm control
See review article re AF treatment
To be published early 2013 Australian Rural Doctor
Case D
Mid 60s male
Found SOB ++ in street
Ambulance called
In ED
SOB at rest
Doesnt want help
Funny smell
Further information
Dishevelled
HR 120 reg BP 9560 Sats 94 RA
Vomiting intermittently
What will you do
Further treatment and
investigation
Further history from patient and collateral
sources
Resuscitation
IV access fluids
Bloods ndash FBC UEC CMP Blood gas
pH 71 pCO2 20 pO2 90 HCO3 10 BE -16
Further treatment and
investigation
Further history from patient and collateral
sources
Resuscitation
IV access fluids
Bloods ndash FBC UEC CMP Blood gas
pH 71 pCO2 20 pO2 90 HCO3 10 BE -16
BSL gt30
Further treatment and
investigation
Treatment
IV fluids ndash caution with Na and cerebral oedema
IV insulin
001 ndash 01 unitskghr
aim for BSL 2mmolL drop per hour
Continue until metabolic correction
Monitor and correct K+ other electrolytes
Monitor urine ketones VBGABG
Identify precipitant
Resolution
Wife arrives and is relieved to find husband
Chairman of Rotary Club
UTI developed whilst wife away for weekend
Questions
Summary
Diagnosis of the breathless patient requires you to look for clueshellip The time course of the illness
Associated symptoms
Known diseases or risk factors for disease
Treatment of illnesses supported by evidence for pneumonia asthma PE AF etc
Interpretation of radiology best done with clinical context
Thankyou
Emergency Department HMO education series
2012
What else should I ask
Travel historyhellip
Other important symptoms of respiratory
disease
Cough
Acute
Chronic
Haemoptysis (cancer TB other infections)
Chest Pain
Daytime sleepiness (obstructive sleep apnea)
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
What are Wells criteria
What are Wells criteria
PERC
D-Dimer
What test do you want to do
Emergency Department HMO education series
2012
What can you see
Emergency Department HMO education series
2012
Filling defect R main pulmonary trunk
Emergency Department HMO education series
2012
Emergency Department HMO education series
2012
Case C Man in 60rsquos
Woke this am very SOB and distressed ndash called
ambulance
Progressive SOB over 6 months
Chronic cough
Usually with white sputum
Now worse with no change in sputum colour
No associated fever
SOB in night ndash gets up
Ankles swollen recently
Heavy smoker (35 pack years)
Admission to local hospital 612 ago with chest pains
Emergency Department HMO education series
2012
Differential diagnosis
CCF with acute exacerbation
Chronic obstructive pulmonary disease
(COPD) with acute infective exacerbation
Anaemia
Emergency Department HMO education series
2012
Exam amp investigationshellip
Unwell RR 36 T 368 HR 90 SR BP 180102
Satrsquos 88 RA
Evidence of work of breathing and use of accessory muscles (which are these)
Pursed lip breathing
Prolonged expiration with wheeze
ABG pH 728 pCO2 60 pO2 55 HCO3 26
What do these show
Do you want a CXR
Emergency Department HMO education series
2012
Emergency Department HMO education series
2012
Diagnosis
Acute cardiac failure ndash APO
Most likely cause
Treatment
ECG ndash filed unsigned and
unseen
Emergency Department HMO education series
2012
Diagnosis
Acute cardiac failure ndash APO
Most likely cause
Treatment
Emergency Department HMO education series
2012
Diagnosis - APO
Acute cardiac failure
Treatment
Medications Nitroglycerin SL topical or IV titrated to avoid hypotension Most rapidly
venodilates reduces LV afterload and corrects myocardial ischaemia
Frusemide IV Despite universal use absolute efficacy is unclear
Ventilatory Assistance Non-invasive ventilation (NIV) reduces mortality by 40 particularly with CPAP
and reduces need to intubate
Emergency Department HMO education series
2012
Case C2 - Male in 60rsquos
Progressive SOB over 6 months worse over 24 hours
Orthopnoea Paroxysmal nocturnal dyspnoea (PND) SOA All present to a minor degree over the 6 months but worse for 24 hours
Palpitations (last 24 hours)
Previous AMI 4 years ago pace maker
Ex-smoker Hypertension (HT) diabetes
Emergency Department HMO education series
2012
Examination
Unwell looking with increased work of breathing
RR 26 afeb HR Irreg 130 BP 10070
Sat 90 RA
JVP 5cm
SOA ++
Displaced apex beat no cardiac murmurs 3rd heart sound present
Normal chest expansion but stony dull percussion in the bases (RgtL) bilateral inspiratory crepitations just above the dull areas
ECG ndash what is your diagnosis
Emergency Department HMO education series
2012
Cardiac failure
Emergency Department HMO education series
2012
Case C2 - Summary
Long standing heart failure with an acute
exacerbation due to new onset rapid AF
Treatment of AF amp heart failure
Antithrombotic strategy
Then rate control
Perhaps rhythm control
See review article re AF treatment
To be published early 2013 Australian Rural Doctor
Case D
Mid 60s male
Found SOB ++ in street
Ambulance called
In ED
SOB at rest
Doesnt want help
Funny smell
Further information
Dishevelled
HR 120 reg BP 9560 Sats 94 RA
Vomiting intermittently
What will you do
Further treatment and
investigation
Further history from patient and collateral
sources
Resuscitation
IV access fluids
Bloods ndash FBC UEC CMP Blood gas
pH 71 pCO2 20 pO2 90 HCO3 10 BE -16
Further treatment and
investigation
Further history from patient and collateral
sources
Resuscitation
IV access fluids
Bloods ndash FBC UEC CMP Blood gas
pH 71 pCO2 20 pO2 90 HCO3 10 BE -16
BSL gt30
Further treatment and
investigation
Treatment
IV fluids ndash caution with Na and cerebral oedema
IV insulin
001 ndash 01 unitskghr
aim for BSL 2mmolL drop per hour
Continue until metabolic correction
Monitor and correct K+ other electrolytes
Monitor urine ketones VBGABG
Identify precipitant
Resolution
Wife arrives and is relieved to find husband
Chairman of Rotary Club
UTI developed whilst wife away for weekend
Questions
Summary
Diagnosis of the breathless patient requires you to look for clueshellip The time course of the illness
Associated symptoms
Known diseases or risk factors for disease
Treatment of illnesses supported by evidence for pneumonia asthma PE AF etc
Interpretation of radiology best done with clinical context
Thankyou
Emergency Department HMO education series
2012
What else should I ask
Travel historyhellip
Other important symptoms of respiratory
disease
Cough
Acute
Chronic
Haemoptysis (cancer TB other infections)
Chest Pain
Daytime sleepiness (obstructive sleep apnea)
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
What are Wells criteria
PERC
D-Dimer
What test do you want to do
Emergency Department HMO education series
2012
What can you see
Emergency Department HMO education series
2012
Filling defect R main pulmonary trunk
Emergency Department HMO education series
2012
Emergency Department HMO education series
2012
Case C Man in 60rsquos
Woke this am very SOB and distressed ndash called
ambulance
Progressive SOB over 6 months
Chronic cough
Usually with white sputum
Now worse with no change in sputum colour
No associated fever
SOB in night ndash gets up
Ankles swollen recently
Heavy smoker (35 pack years)
Admission to local hospital 612 ago with chest pains
Emergency Department HMO education series
2012
Differential diagnosis
CCF with acute exacerbation
Chronic obstructive pulmonary disease
(COPD) with acute infective exacerbation
Anaemia
Emergency Department HMO education series
2012
Exam amp investigationshellip
Unwell RR 36 T 368 HR 90 SR BP 180102
Satrsquos 88 RA
Evidence of work of breathing and use of accessory muscles (which are these)
Pursed lip breathing
Prolonged expiration with wheeze
ABG pH 728 pCO2 60 pO2 55 HCO3 26
What do these show
Do you want a CXR
Emergency Department HMO education series
2012
Emergency Department HMO education series
2012
Diagnosis
Acute cardiac failure ndash APO
Most likely cause
Treatment
ECG ndash filed unsigned and
unseen
Emergency Department HMO education series
2012
Diagnosis
Acute cardiac failure ndash APO
Most likely cause
Treatment
Emergency Department HMO education series
2012
Diagnosis - APO
Acute cardiac failure
Treatment
Medications Nitroglycerin SL topical or IV titrated to avoid hypotension Most rapidly
venodilates reduces LV afterload and corrects myocardial ischaemia
Frusemide IV Despite universal use absolute efficacy is unclear
Ventilatory Assistance Non-invasive ventilation (NIV) reduces mortality by 40 particularly with CPAP
and reduces need to intubate
Emergency Department HMO education series
2012
Case C2 - Male in 60rsquos
Progressive SOB over 6 months worse over 24 hours
Orthopnoea Paroxysmal nocturnal dyspnoea (PND) SOA All present to a minor degree over the 6 months but worse for 24 hours
Palpitations (last 24 hours)
Previous AMI 4 years ago pace maker
Ex-smoker Hypertension (HT) diabetes
Emergency Department HMO education series
2012
Examination
Unwell looking with increased work of breathing
RR 26 afeb HR Irreg 130 BP 10070
Sat 90 RA
JVP 5cm
SOA ++
Displaced apex beat no cardiac murmurs 3rd heart sound present
Normal chest expansion but stony dull percussion in the bases (RgtL) bilateral inspiratory crepitations just above the dull areas
ECG ndash what is your diagnosis
Emergency Department HMO education series
2012
Cardiac failure
Emergency Department HMO education series
2012
Case C2 - Summary
Long standing heart failure with an acute
exacerbation due to new onset rapid AF
Treatment of AF amp heart failure
Antithrombotic strategy
Then rate control
Perhaps rhythm control
See review article re AF treatment
To be published early 2013 Australian Rural Doctor
Case D
Mid 60s male
Found SOB ++ in street
Ambulance called
In ED
SOB at rest
Doesnt want help
Funny smell
Further information
Dishevelled
HR 120 reg BP 9560 Sats 94 RA
Vomiting intermittently
What will you do
Further treatment and
investigation
Further history from patient and collateral
sources
Resuscitation
IV access fluids
Bloods ndash FBC UEC CMP Blood gas
pH 71 pCO2 20 pO2 90 HCO3 10 BE -16
Further treatment and
investigation
Further history from patient and collateral
sources
Resuscitation
IV access fluids
Bloods ndash FBC UEC CMP Blood gas
pH 71 pCO2 20 pO2 90 HCO3 10 BE -16
BSL gt30
Further treatment and
investigation
Treatment
IV fluids ndash caution with Na and cerebral oedema
IV insulin
001 ndash 01 unitskghr
aim for BSL 2mmolL drop per hour
Continue until metabolic correction
Monitor and correct K+ other electrolytes
Monitor urine ketones VBGABG
Identify precipitant
Resolution
Wife arrives and is relieved to find husband
Chairman of Rotary Club
UTI developed whilst wife away for weekend
Questions
Summary
Diagnosis of the breathless patient requires you to look for clueshellip The time course of the illness
Associated symptoms
Known diseases or risk factors for disease
Treatment of illnesses supported by evidence for pneumonia asthma PE AF etc
Interpretation of radiology best done with clinical context
Thankyou
Emergency Department HMO education series
2012
What else should I ask
Travel historyhellip
Other important symptoms of respiratory
disease
Cough
Acute
Chronic
Haemoptysis (cancer TB other infections)
Chest Pain
Daytime sleepiness (obstructive sleep apnea)
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
PERC
D-Dimer
What test do you want to do
Emergency Department HMO education series
2012
What can you see
Emergency Department HMO education series
2012
Filling defect R main pulmonary trunk
Emergency Department HMO education series
2012
Emergency Department HMO education series
2012
Case C Man in 60rsquos
Woke this am very SOB and distressed ndash called
ambulance
Progressive SOB over 6 months
Chronic cough
Usually with white sputum
Now worse with no change in sputum colour
No associated fever
SOB in night ndash gets up
Ankles swollen recently
Heavy smoker (35 pack years)
Admission to local hospital 612 ago with chest pains
Emergency Department HMO education series
2012
Differential diagnosis
CCF with acute exacerbation
Chronic obstructive pulmonary disease
(COPD) with acute infective exacerbation
Anaemia
Emergency Department HMO education series
2012
Exam amp investigationshellip
Unwell RR 36 T 368 HR 90 SR BP 180102
Satrsquos 88 RA
Evidence of work of breathing and use of accessory muscles (which are these)
Pursed lip breathing
Prolonged expiration with wheeze
ABG pH 728 pCO2 60 pO2 55 HCO3 26
What do these show
Do you want a CXR
Emergency Department HMO education series
2012
Emergency Department HMO education series
2012
Diagnosis
Acute cardiac failure ndash APO
Most likely cause
Treatment
ECG ndash filed unsigned and
unseen
Emergency Department HMO education series
2012
Diagnosis
Acute cardiac failure ndash APO
Most likely cause
Treatment
Emergency Department HMO education series
2012
Diagnosis - APO
Acute cardiac failure
Treatment
Medications Nitroglycerin SL topical or IV titrated to avoid hypotension Most rapidly
venodilates reduces LV afterload and corrects myocardial ischaemia
Frusemide IV Despite universal use absolute efficacy is unclear
Ventilatory Assistance Non-invasive ventilation (NIV) reduces mortality by 40 particularly with CPAP
and reduces need to intubate
Emergency Department HMO education series
2012
Case C2 - Male in 60rsquos
Progressive SOB over 6 months worse over 24 hours
Orthopnoea Paroxysmal nocturnal dyspnoea (PND) SOA All present to a minor degree over the 6 months but worse for 24 hours
Palpitations (last 24 hours)
Previous AMI 4 years ago pace maker
Ex-smoker Hypertension (HT) diabetes
Emergency Department HMO education series
2012
Examination
Unwell looking with increased work of breathing
RR 26 afeb HR Irreg 130 BP 10070
Sat 90 RA
JVP 5cm
SOA ++
Displaced apex beat no cardiac murmurs 3rd heart sound present
Normal chest expansion but stony dull percussion in the bases (RgtL) bilateral inspiratory crepitations just above the dull areas
ECG ndash what is your diagnosis
Emergency Department HMO education series
2012
Cardiac failure
Emergency Department HMO education series
2012
Case C2 - Summary
Long standing heart failure with an acute
exacerbation due to new onset rapid AF
Treatment of AF amp heart failure
Antithrombotic strategy
Then rate control
Perhaps rhythm control
See review article re AF treatment
To be published early 2013 Australian Rural Doctor
Case D
Mid 60s male
Found SOB ++ in street
Ambulance called
In ED
SOB at rest
Doesnt want help
Funny smell
Further information
Dishevelled
HR 120 reg BP 9560 Sats 94 RA
Vomiting intermittently
What will you do
Further treatment and
investigation
Further history from patient and collateral
sources
Resuscitation
IV access fluids
Bloods ndash FBC UEC CMP Blood gas
pH 71 pCO2 20 pO2 90 HCO3 10 BE -16
Further treatment and
investigation
Further history from patient and collateral
sources
Resuscitation
IV access fluids
Bloods ndash FBC UEC CMP Blood gas
pH 71 pCO2 20 pO2 90 HCO3 10 BE -16
BSL gt30
Further treatment and
investigation
Treatment
IV fluids ndash caution with Na and cerebral oedema
IV insulin
001 ndash 01 unitskghr
aim for BSL 2mmolL drop per hour
Continue until metabolic correction
Monitor and correct K+ other electrolytes
Monitor urine ketones VBGABG
Identify precipitant
Resolution
Wife arrives and is relieved to find husband
Chairman of Rotary Club
UTI developed whilst wife away for weekend
Questions
Summary
Diagnosis of the breathless patient requires you to look for clueshellip The time course of the illness
Associated symptoms
Known diseases or risk factors for disease
Treatment of illnesses supported by evidence for pneumonia asthma PE AF etc
Interpretation of radiology best done with clinical context
Thankyou
Emergency Department HMO education series
2012
What else should I ask
Travel historyhellip
Other important symptoms of respiratory
disease
Cough
Acute
Chronic
Haemoptysis (cancer TB other infections)
Chest Pain
Daytime sleepiness (obstructive sleep apnea)
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
D-Dimer
What test do you want to do
Emergency Department HMO education series
2012
What can you see
Emergency Department HMO education series
2012
Filling defect R main pulmonary trunk
Emergency Department HMO education series
2012
Emergency Department HMO education series
2012
Case C Man in 60rsquos
Woke this am very SOB and distressed ndash called
ambulance
Progressive SOB over 6 months
Chronic cough
Usually with white sputum
Now worse with no change in sputum colour
No associated fever
SOB in night ndash gets up
Ankles swollen recently
Heavy smoker (35 pack years)
Admission to local hospital 612 ago with chest pains
Emergency Department HMO education series
2012
Differential diagnosis
CCF with acute exacerbation
Chronic obstructive pulmonary disease
(COPD) with acute infective exacerbation
Anaemia
Emergency Department HMO education series
2012
Exam amp investigationshellip
Unwell RR 36 T 368 HR 90 SR BP 180102
Satrsquos 88 RA
Evidence of work of breathing and use of accessory muscles (which are these)
Pursed lip breathing
Prolonged expiration with wheeze
ABG pH 728 pCO2 60 pO2 55 HCO3 26
What do these show
Do you want a CXR
Emergency Department HMO education series
2012
Emergency Department HMO education series
2012
Diagnosis
Acute cardiac failure ndash APO
Most likely cause
Treatment
ECG ndash filed unsigned and
unseen
Emergency Department HMO education series
2012
Diagnosis
Acute cardiac failure ndash APO
Most likely cause
Treatment
Emergency Department HMO education series
2012
Diagnosis - APO
Acute cardiac failure
Treatment
Medications Nitroglycerin SL topical or IV titrated to avoid hypotension Most rapidly
venodilates reduces LV afterload and corrects myocardial ischaemia
Frusemide IV Despite universal use absolute efficacy is unclear
Ventilatory Assistance Non-invasive ventilation (NIV) reduces mortality by 40 particularly with CPAP
and reduces need to intubate
Emergency Department HMO education series
2012
Case C2 - Male in 60rsquos
Progressive SOB over 6 months worse over 24 hours
Orthopnoea Paroxysmal nocturnal dyspnoea (PND) SOA All present to a minor degree over the 6 months but worse for 24 hours
Palpitations (last 24 hours)
Previous AMI 4 years ago pace maker
Ex-smoker Hypertension (HT) diabetes
Emergency Department HMO education series
2012
Examination
Unwell looking with increased work of breathing
RR 26 afeb HR Irreg 130 BP 10070
Sat 90 RA
JVP 5cm
SOA ++
Displaced apex beat no cardiac murmurs 3rd heart sound present
Normal chest expansion but stony dull percussion in the bases (RgtL) bilateral inspiratory crepitations just above the dull areas
ECG ndash what is your diagnosis
Emergency Department HMO education series
2012
Cardiac failure
Emergency Department HMO education series
2012
Case C2 - Summary
Long standing heart failure with an acute
exacerbation due to new onset rapid AF
Treatment of AF amp heart failure
Antithrombotic strategy
Then rate control
Perhaps rhythm control
See review article re AF treatment
To be published early 2013 Australian Rural Doctor
Case D
Mid 60s male
Found SOB ++ in street
Ambulance called
In ED
SOB at rest
Doesnt want help
Funny smell
Further information
Dishevelled
HR 120 reg BP 9560 Sats 94 RA
Vomiting intermittently
What will you do
Further treatment and
investigation
Further history from patient and collateral
sources
Resuscitation
IV access fluids
Bloods ndash FBC UEC CMP Blood gas
pH 71 pCO2 20 pO2 90 HCO3 10 BE -16
Further treatment and
investigation
Further history from patient and collateral
sources
Resuscitation
IV access fluids
Bloods ndash FBC UEC CMP Blood gas
pH 71 pCO2 20 pO2 90 HCO3 10 BE -16
BSL gt30
Further treatment and
investigation
Treatment
IV fluids ndash caution with Na and cerebral oedema
IV insulin
001 ndash 01 unitskghr
aim for BSL 2mmolL drop per hour
Continue until metabolic correction
Monitor and correct K+ other electrolytes
Monitor urine ketones VBGABG
Identify precipitant
Resolution
Wife arrives and is relieved to find husband
Chairman of Rotary Club
UTI developed whilst wife away for weekend
Questions
Summary
Diagnosis of the breathless patient requires you to look for clueshellip The time course of the illness
Associated symptoms
Known diseases or risk factors for disease
Treatment of illnesses supported by evidence for pneumonia asthma PE AF etc
Interpretation of radiology best done with clinical context
Thankyou
Emergency Department HMO education series
2012
What else should I ask
Travel historyhellip
Other important symptoms of respiratory
disease
Cough
Acute
Chronic
Haemoptysis (cancer TB other infections)
Chest Pain
Daytime sleepiness (obstructive sleep apnea)
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
What test do you want to do
Emergency Department HMO education series
2012
What can you see
Emergency Department HMO education series
2012
Filling defect R main pulmonary trunk
Emergency Department HMO education series
2012
Emergency Department HMO education series
2012
Case C Man in 60rsquos
Woke this am very SOB and distressed ndash called
ambulance
Progressive SOB over 6 months
Chronic cough
Usually with white sputum
Now worse with no change in sputum colour
No associated fever
SOB in night ndash gets up
Ankles swollen recently
Heavy smoker (35 pack years)
Admission to local hospital 612 ago with chest pains
Emergency Department HMO education series
2012
Differential diagnosis
CCF with acute exacerbation
Chronic obstructive pulmonary disease
(COPD) with acute infective exacerbation
Anaemia
Emergency Department HMO education series
2012
Exam amp investigationshellip
Unwell RR 36 T 368 HR 90 SR BP 180102
Satrsquos 88 RA
Evidence of work of breathing and use of accessory muscles (which are these)
Pursed lip breathing
Prolonged expiration with wheeze
ABG pH 728 pCO2 60 pO2 55 HCO3 26
What do these show
Do you want a CXR
Emergency Department HMO education series
2012
Emergency Department HMO education series
2012
Diagnosis
Acute cardiac failure ndash APO
Most likely cause
Treatment
ECG ndash filed unsigned and
unseen
Emergency Department HMO education series
2012
Diagnosis
Acute cardiac failure ndash APO
Most likely cause
Treatment
Emergency Department HMO education series
2012
Diagnosis - APO
Acute cardiac failure
Treatment
Medications Nitroglycerin SL topical or IV titrated to avoid hypotension Most rapidly
venodilates reduces LV afterload and corrects myocardial ischaemia
Frusemide IV Despite universal use absolute efficacy is unclear
Ventilatory Assistance Non-invasive ventilation (NIV) reduces mortality by 40 particularly with CPAP
and reduces need to intubate
Emergency Department HMO education series
2012
Case C2 - Male in 60rsquos
Progressive SOB over 6 months worse over 24 hours
Orthopnoea Paroxysmal nocturnal dyspnoea (PND) SOA All present to a minor degree over the 6 months but worse for 24 hours
Palpitations (last 24 hours)
Previous AMI 4 years ago pace maker
Ex-smoker Hypertension (HT) diabetes
Emergency Department HMO education series
2012
Examination
Unwell looking with increased work of breathing
RR 26 afeb HR Irreg 130 BP 10070
Sat 90 RA
JVP 5cm
SOA ++
Displaced apex beat no cardiac murmurs 3rd heart sound present
Normal chest expansion but stony dull percussion in the bases (RgtL) bilateral inspiratory crepitations just above the dull areas
ECG ndash what is your diagnosis
Emergency Department HMO education series
2012
Cardiac failure
Emergency Department HMO education series
2012
Case C2 - Summary
Long standing heart failure with an acute
exacerbation due to new onset rapid AF
Treatment of AF amp heart failure
Antithrombotic strategy
Then rate control
Perhaps rhythm control
See review article re AF treatment
To be published early 2013 Australian Rural Doctor
Case D
Mid 60s male
Found SOB ++ in street
Ambulance called
In ED
SOB at rest
Doesnt want help
Funny smell
Further information
Dishevelled
HR 120 reg BP 9560 Sats 94 RA
Vomiting intermittently
What will you do
Further treatment and
investigation
Further history from patient and collateral
sources
Resuscitation
IV access fluids
Bloods ndash FBC UEC CMP Blood gas
pH 71 pCO2 20 pO2 90 HCO3 10 BE -16
Further treatment and
investigation
Further history from patient and collateral
sources
Resuscitation
IV access fluids
Bloods ndash FBC UEC CMP Blood gas
pH 71 pCO2 20 pO2 90 HCO3 10 BE -16
BSL gt30
Further treatment and
investigation
Treatment
IV fluids ndash caution with Na and cerebral oedema
IV insulin
001 ndash 01 unitskghr
aim for BSL 2mmolL drop per hour
Continue until metabolic correction
Monitor and correct K+ other electrolytes
Monitor urine ketones VBGABG
Identify precipitant
Resolution
Wife arrives and is relieved to find husband
Chairman of Rotary Club
UTI developed whilst wife away for weekend
Questions
Summary
Diagnosis of the breathless patient requires you to look for clueshellip The time course of the illness
Associated symptoms
Known diseases or risk factors for disease
Treatment of illnesses supported by evidence for pneumonia asthma PE AF etc
Interpretation of radiology best done with clinical context
Thankyou
Emergency Department HMO education series
2012
What else should I ask
Travel historyhellip
Other important symptoms of respiratory
disease
Cough
Acute
Chronic
Haemoptysis (cancer TB other infections)
Chest Pain
Daytime sleepiness (obstructive sleep apnea)
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Emergency Department HMO education series
2012
What can you see
Emergency Department HMO education series
2012
Filling defect R main pulmonary trunk
Emergency Department HMO education series
2012
Emergency Department HMO education series
2012
Case C Man in 60rsquos
Woke this am very SOB and distressed ndash called
ambulance
Progressive SOB over 6 months
Chronic cough
Usually with white sputum
Now worse with no change in sputum colour
No associated fever
SOB in night ndash gets up
Ankles swollen recently
Heavy smoker (35 pack years)
Admission to local hospital 612 ago with chest pains
Emergency Department HMO education series
2012
Differential diagnosis
CCF with acute exacerbation
Chronic obstructive pulmonary disease
(COPD) with acute infective exacerbation
Anaemia
Emergency Department HMO education series
2012
Exam amp investigationshellip
Unwell RR 36 T 368 HR 90 SR BP 180102
Satrsquos 88 RA
Evidence of work of breathing and use of accessory muscles (which are these)
Pursed lip breathing
Prolonged expiration with wheeze
ABG pH 728 pCO2 60 pO2 55 HCO3 26
What do these show
Do you want a CXR
Emergency Department HMO education series
2012
Emergency Department HMO education series
2012
Diagnosis
Acute cardiac failure ndash APO
Most likely cause
Treatment
ECG ndash filed unsigned and
unseen
Emergency Department HMO education series
2012
Diagnosis
Acute cardiac failure ndash APO
Most likely cause
Treatment
Emergency Department HMO education series
2012
Diagnosis - APO
Acute cardiac failure
Treatment
Medications Nitroglycerin SL topical or IV titrated to avoid hypotension Most rapidly
venodilates reduces LV afterload and corrects myocardial ischaemia
Frusemide IV Despite universal use absolute efficacy is unclear
Ventilatory Assistance Non-invasive ventilation (NIV) reduces mortality by 40 particularly with CPAP
and reduces need to intubate
Emergency Department HMO education series
2012
Case C2 - Male in 60rsquos
Progressive SOB over 6 months worse over 24 hours
Orthopnoea Paroxysmal nocturnal dyspnoea (PND) SOA All present to a minor degree over the 6 months but worse for 24 hours
Palpitations (last 24 hours)
Previous AMI 4 years ago pace maker
Ex-smoker Hypertension (HT) diabetes
Emergency Department HMO education series
2012
Examination
Unwell looking with increased work of breathing
RR 26 afeb HR Irreg 130 BP 10070
Sat 90 RA
JVP 5cm
SOA ++
Displaced apex beat no cardiac murmurs 3rd heart sound present
Normal chest expansion but stony dull percussion in the bases (RgtL) bilateral inspiratory crepitations just above the dull areas
ECG ndash what is your diagnosis
Emergency Department HMO education series
2012
Cardiac failure
Emergency Department HMO education series
2012
Case C2 - Summary
Long standing heart failure with an acute
exacerbation due to new onset rapid AF
Treatment of AF amp heart failure
Antithrombotic strategy
Then rate control
Perhaps rhythm control
See review article re AF treatment
To be published early 2013 Australian Rural Doctor
Case D
Mid 60s male
Found SOB ++ in street
Ambulance called
In ED
SOB at rest
Doesnt want help
Funny smell
Further information
Dishevelled
HR 120 reg BP 9560 Sats 94 RA
Vomiting intermittently
What will you do
Further treatment and
investigation
Further history from patient and collateral
sources
Resuscitation
IV access fluids
Bloods ndash FBC UEC CMP Blood gas
pH 71 pCO2 20 pO2 90 HCO3 10 BE -16
Further treatment and
investigation
Further history from patient and collateral
sources
Resuscitation
IV access fluids
Bloods ndash FBC UEC CMP Blood gas
pH 71 pCO2 20 pO2 90 HCO3 10 BE -16
BSL gt30
Further treatment and
investigation
Treatment
IV fluids ndash caution with Na and cerebral oedema
IV insulin
001 ndash 01 unitskghr
aim for BSL 2mmolL drop per hour
Continue until metabolic correction
Monitor and correct K+ other electrolytes
Monitor urine ketones VBGABG
Identify precipitant
Resolution
Wife arrives and is relieved to find husband
Chairman of Rotary Club
UTI developed whilst wife away for weekend
Questions
Summary
Diagnosis of the breathless patient requires you to look for clueshellip The time course of the illness
Associated symptoms
Known diseases or risk factors for disease
Treatment of illnesses supported by evidence for pneumonia asthma PE AF etc
Interpretation of radiology best done with clinical context
Thankyou
Emergency Department HMO education series
2012
What else should I ask
Travel historyhellip
Other important symptoms of respiratory
disease
Cough
Acute
Chronic
Haemoptysis (cancer TB other infections)
Chest Pain
Daytime sleepiness (obstructive sleep apnea)
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Emergency Department HMO education series
2012
Filling defect R main pulmonary trunk
Emergency Department HMO education series
2012
Emergency Department HMO education series
2012
Case C Man in 60rsquos
Woke this am very SOB and distressed ndash called
ambulance
Progressive SOB over 6 months
Chronic cough
Usually with white sputum
Now worse with no change in sputum colour
No associated fever
SOB in night ndash gets up
Ankles swollen recently
Heavy smoker (35 pack years)
Admission to local hospital 612 ago with chest pains
Emergency Department HMO education series
2012
Differential diagnosis
CCF with acute exacerbation
Chronic obstructive pulmonary disease
(COPD) with acute infective exacerbation
Anaemia
Emergency Department HMO education series
2012
Exam amp investigationshellip
Unwell RR 36 T 368 HR 90 SR BP 180102
Satrsquos 88 RA
Evidence of work of breathing and use of accessory muscles (which are these)
Pursed lip breathing
Prolonged expiration with wheeze
ABG pH 728 pCO2 60 pO2 55 HCO3 26
What do these show
Do you want a CXR
Emergency Department HMO education series
2012
Emergency Department HMO education series
2012
Diagnosis
Acute cardiac failure ndash APO
Most likely cause
Treatment
ECG ndash filed unsigned and
unseen
Emergency Department HMO education series
2012
Diagnosis
Acute cardiac failure ndash APO
Most likely cause
Treatment
Emergency Department HMO education series
2012
Diagnosis - APO
Acute cardiac failure
Treatment
Medications Nitroglycerin SL topical or IV titrated to avoid hypotension Most rapidly
venodilates reduces LV afterload and corrects myocardial ischaemia
Frusemide IV Despite universal use absolute efficacy is unclear
Ventilatory Assistance Non-invasive ventilation (NIV) reduces mortality by 40 particularly with CPAP
and reduces need to intubate
Emergency Department HMO education series
2012
Case C2 - Male in 60rsquos
Progressive SOB over 6 months worse over 24 hours
Orthopnoea Paroxysmal nocturnal dyspnoea (PND) SOA All present to a minor degree over the 6 months but worse for 24 hours
Palpitations (last 24 hours)
Previous AMI 4 years ago pace maker
Ex-smoker Hypertension (HT) diabetes
Emergency Department HMO education series
2012
Examination
Unwell looking with increased work of breathing
RR 26 afeb HR Irreg 130 BP 10070
Sat 90 RA
JVP 5cm
SOA ++
Displaced apex beat no cardiac murmurs 3rd heart sound present
Normal chest expansion but stony dull percussion in the bases (RgtL) bilateral inspiratory crepitations just above the dull areas
ECG ndash what is your diagnosis
Emergency Department HMO education series
2012
Cardiac failure
Emergency Department HMO education series
2012
Case C2 - Summary
Long standing heart failure with an acute
exacerbation due to new onset rapid AF
Treatment of AF amp heart failure
Antithrombotic strategy
Then rate control
Perhaps rhythm control
See review article re AF treatment
To be published early 2013 Australian Rural Doctor
Case D
Mid 60s male
Found SOB ++ in street
Ambulance called
In ED
SOB at rest
Doesnt want help
Funny smell
Further information
Dishevelled
HR 120 reg BP 9560 Sats 94 RA
Vomiting intermittently
What will you do
Further treatment and
investigation
Further history from patient and collateral
sources
Resuscitation
IV access fluids
Bloods ndash FBC UEC CMP Blood gas
pH 71 pCO2 20 pO2 90 HCO3 10 BE -16
Further treatment and
investigation
Further history from patient and collateral
sources
Resuscitation
IV access fluids
Bloods ndash FBC UEC CMP Blood gas
pH 71 pCO2 20 pO2 90 HCO3 10 BE -16
BSL gt30
Further treatment and
investigation
Treatment
IV fluids ndash caution with Na and cerebral oedema
IV insulin
001 ndash 01 unitskghr
aim for BSL 2mmolL drop per hour
Continue until metabolic correction
Monitor and correct K+ other electrolytes
Monitor urine ketones VBGABG
Identify precipitant
Resolution
Wife arrives and is relieved to find husband
Chairman of Rotary Club
UTI developed whilst wife away for weekend
Questions
Summary
Diagnosis of the breathless patient requires you to look for clueshellip The time course of the illness
Associated symptoms
Known diseases or risk factors for disease
Treatment of illnesses supported by evidence for pneumonia asthma PE AF etc
Interpretation of radiology best done with clinical context
Thankyou
Emergency Department HMO education series
2012
What else should I ask
Travel historyhellip
Other important symptoms of respiratory
disease
Cough
Acute
Chronic
Haemoptysis (cancer TB other infections)
Chest Pain
Daytime sleepiness (obstructive sleep apnea)
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Emergency Department HMO education series
2012
Emergency Department HMO education series
2012
Case C Man in 60rsquos
Woke this am very SOB and distressed ndash called
ambulance
Progressive SOB over 6 months
Chronic cough
Usually with white sputum
Now worse with no change in sputum colour
No associated fever
SOB in night ndash gets up
Ankles swollen recently
Heavy smoker (35 pack years)
Admission to local hospital 612 ago with chest pains
Emergency Department HMO education series
2012
Differential diagnosis
CCF with acute exacerbation
Chronic obstructive pulmonary disease
(COPD) with acute infective exacerbation
Anaemia
Emergency Department HMO education series
2012
Exam amp investigationshellip
Unwell RR 36 T 368 HR 90 SR BP 180102
Satrsquos 88 RA
Evidence of work of breathing and use of accessory muscles (which are these)
Pursed lip breathing
Prolonged expiration with wheeze
ABG pH 728 pCO2 60 pO2 55 HCO3 26
What do these show
Do you want a CXR
Emergency Department HMO education series
2012
Emergency Department HMO education series
2012
Diagnosis
Acute cardiac failure ndash APO
Most likely cause
Treatment
ECG ndash filed unsigned and
unseen
Emergency Department HMO education series
2012
Diagnosis
Acute cardiac failure ndash APO
Most likely cause
Treatment
Emergency Department HMO education series
2012
Diagnosis - APO
Acute cardiac failure
Treatment
Medications Nitroglycerin SL topical or IV titrated to avoid hypotension Most rapidly
venodilates reduces LV afterload and corrects myocardial ischaemia
Frusemide IV Despite universal use absolute efficacy is unclear
Ventilatory Assistance Non-invasive ventilation (NIV) reduces mortality by 40 particularly with CPAP
and reduces need to intubate
Emergency Department HMO education series
2012
Case C2 - Male in 60rsquos
Progressive SOB over 6 months worse over 24 hours
Orthopnoea Paroxysmal nocturnal dyspnoea (PND) SOA All present to a minor degree over the 6 months but worse for 24 hours
Palpitations (last 24 hours)
Previous AMI 4 years ago pace maker
Ex-smoker Hypertension (HT) diabetes
Emergency Department HMO education series
2012
Examination
Unwell looking with increased work of breathing
RR 26 afeb HR Irreg 130 BP 10070
Sat 90 RA
JVP 5cm
SOA ++
Displaced apex beat no cardiac murmurs 3rd heart sound present
Normal chest expansion but stony dull percussion in the bases (RgtL) bilateral inspiratory crepitations just above the dull areas
ECG ndash what is your diagnosis
Emergency Department HMO education series
2012
Cardiac failure
Emergency Department HMO education series
2012
Case C2 - Summary
Long standing heart failure with an acute
exacerbation due to new onset rapid AF
Treatment of AF amp heart failure
Antithrombotic strategy
Then rate control
Perhaps rhythm control
See review article re AF treatment
To be published early 2013 Australian Rural Doctor
Case D
Mid 60s male
Found SOB ++ in street
Ambulance called
In ED
SOB at rest
Doesnt want help
Funny smell
Further information
Dishevelled
HR 120 reg BP 9560 Sats 94 RA
Vomiting intermittently
What will you do
Further treatment and
investigation
Further history from patient and collateral
sources
Resuscitation
IV access fluids
Bloods ndash FBC UEC CMP Blood gas
pH 71 pCO2 20 pO2 90 HCO3 10 BE -16
Further treatment and
investigation
Further history from patient and collateral
sources
Resuscitation
IV access fluids
Bloods ndash FBC UEC CMP Blood gas
pH 71 pCO2 20 pO2 90 HCO3 10 BE -16
BSL gt30
Further treatment and
investigation
Treatment
IV fluids ndash caution with Na and cerebral oedema
IV insulin
001 ndash 01 unitskghr
aim for BSL 2mmolL drop per hour
Continue until metabolic correction
Monitor and correct K+ other electrolytes
Monitor urine ketones VBGABG
Identify precipitant
Resolution
Wife arrives and is relieved to find husband
Chairman of Rotary Club
UTI developed whilst wife away for weekend
Questions
Summary
Diagnosis of the breathless patient requires you to look for clueshellip The time course of the illness
Associated symptoms
Known diseases or risk factors for disease
Treatment of illnesses supported by evidence for pneumonia asthma PE AF etc
Interpretation of radiology best done with clinical context
Thankyou
Emergency Department HMO education series
2012
What else should I ask
Travel historyhellip
Other important symptoms of respiratory
disease
Cough
Acute
Chronic
Haemoptysis (cancer TB other infections)
Chest Pain
Daytime sleepiness (obstructive sleep apnea)
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Emergency Department HMO education series
2012
Case C Man in 60rsquos
Woke this am very SOB and distressed ndash called
ambulance
Progressive SOB over 6 months
Chronic cough
Usually with white sputum
Now worse with no change in sputum colour
No associated fever
SOB in night ndash gets up
Ankles swollen recently
Heavy smoker (35 pack years)
Admission to local hospital 612 ago with chest pains
Emergency Department HMO education series
2012
Differential diagnosis
CCF with acute exacerbation
Chronic obstructive pulmonary disease
(COPD) with acute infective exacerbation
Anaemia
Emergency Department HMO education series
2012
Exam amp investigationshellip
Unwell RR 36 T 368 HR 90 SR BP 180102
Satrsquos 88 RA
Evidence of work of breathing and use of accessory muscles (which are these)
Pursed lip breathing
Prolonged expiration with wheeze
ABG pH 728 pCO2 60 pO2 55 HCO3 26
What do these show
Do you want a CXR
Emergency Department HMO education series
2012
Emergency Department HMO education series
2012
Diagnosis
Acute cardiac failure ndash APO
Most likely cause
Treatment
ECG ndash filed unsigned and
unseen
Emergency Department HMO education series
2012
Diagnosis
Acute cardiac failure ndash APO
Most likely cause
Treatment
Emergency Department HMO education series
2012
Diagnosis - APO
Acute cardiac failure
Treatment
Medications Nitroglycerin SL topical or IV titrated to avoid hypotension Most rapidly
venodilates reduces LV afterload and corrects myocardial ischaemia
Frusemide IV Despite universal use absolute efficacy is unclear
Ventilatory Assistance Non-invasive ventilation (NIV) reduces mortality by 40 particularly with CPAP
and reduces need to intubate
Emergency Department HMO education series
2012
Case C2 - Male in 60rsquos
Progressive SOB over 6 months worse over 24 hours
Orthopnoea Paroxysmal nocturnal dyspnoea (PND) SOA All present to a minor degree over the 6 months but worse for 24 hours
Palpitations (last 24 hours)
Previous AMI 4 years ago pace maker
Ex-smoker Hypertension (HT) diabetes
Emergency Department HMO education series
2012
Examination
Unwell looking with increased work of breathing
RR 26 afeb HR Irreg 130 BP 10070
Sat 90 RA
JVP 5cm
SOA ++
Displaced apex beat no cardiac murmurs 3rd heart sound present
Normal chest expansion but stony dull percussion in the bases (RgtL) bilateral inspiratory crepitations just above the dull areas
ECG ndash what is your diagnosis
Emergency Department HMO education series
2012
Cardiac failure
Emergency Department HMO education series
2012
Case C2 - Summary
Long standing heart failure with an acute
exacerbation due to new onset rapid AF
Treatment of AF amp heart failure
Antithrombotic strategy
Then rate control
Perhaps rhythm control
See review article re AF treatment
To be published early 2013 Australian Rural Doctor
Case D
Mid 60s male
Found SOB ++ in street
Ambulance called
In ED
SOB at rest
Doesnt want help
Funny smell
Further information
Dishevelled
HR 120 reg BP 9560 Sats 94 RA
Vomiting intermittently
What will you do
Further treatment and
investigation
Further history from patient and collateral
sources
Resuscitation
IV access fluids
Bloods ndash FBC UEC CMP Blood gas
pH 71 pCO2 20 pO2 90 HCO3 10 BE -16
Further treatment and
investigation
Further history from patient and collateral
sources
Resuscitation
IV access fluids
Bloods ndash FBC UEC CMP Blood gas
pH 71 pCO2 20 pO2 90 HCO3 10 BE -16
BSL gt30
Further treatment and
investigation
Treatment
IV fluids ndash caution with Na and cerebral oedema
IV insulin
001 ndash 01 unitskghr
aim for BSL 2mmolL drop per hour
Continue until metabolic correction
Monitor and correct K+ other electrolytes
Monitor urine ketones VBGABG
Identify precipitant
Resolution
Wife arrives and is relieved to find husband
Chairman of Rotary Club
UTI developed whilst wife away for weekend
Questions
Summary
Diagnosis of the breathless patient requires you to look for clueshellip The time course of the illness
Associated symptoms
Known diseases or risk factors for disease
Treatment of illnesses supported by evidence for pneumonia asthma PE AF etc
Interpretation of radiology best done with clinical context
Thankyou
Emergency Department HMO education series
2012
What else should I ask
Travel historyhellip
Other important symptoms of respiratory
disease
Cough
Acute
Chronic
Haemoptysis (cancer TB other infections)
Chest Pain
Daytime sleepiness (obstructive sleep apnea)
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Emergency Department HMO education series
2012
Differential diagnosis
CCF with acute exacerbation
Chronic obstructive pulmonary disease
(COPD) with acute infective exacerbation
Anaemia
Emergency Department HMO education series
2012
Exam amp investigationshellip
Unwell RR 36 T 368 HR 90 SR BP 180102
Satrsquos 88 RA
Evidence of work of breathing and use of accessory muscles (which are these)
Pursed lip breathing
Prolonged expiration with wheeze
ABG pH 728 pCO2 60 pO2 55 HCO3 26
What do these show
Do you want a CXR
Emergency Department HMO education series
2012
Emergency Department HMO education series
2012
Diagnosis
Acute cardiac failure ndash APO
Most likely cause
Treatment
ECG ndash filed unsigned and
unseen
Emergency Department HMO education series
2012
Diagnosis
Acute cardiac failure ndash APO
Most likely cause
Treatment
Emergency Department HMO education series
2012
Diagnosis - APO
Acute cardiac failure
Treatment
Medications Nitroglycerin SL topical or IV titrated to avoid hypotension Most rapidly
venodilates reduces LV afterload and corrects myocardial ischaemia
Frusemide IV Despite universal use absolute efficacy is unclear
Ventilatory Assistance Non-invasive ventilation (NIV) reduces mortality by 40 particularly with CPAP
and reduces need to intubate
Emergency Department HMO education series
2012
Case C2 - Male in 60rsquos
Progressive SOB over 6 months worse over 24 hours
Orthopnoea Paroxysmal nocturnal dyspnoea (PND) SOA All present to a minor degree over the 6 months but worse for 24 hours
Palpitations (last 24 hours)
Previous AMI 4 years ago pace maker
Ex-smoker Hypertension (HT) diabetes
Emergency Department HMO education series
2012
Examination
Unwell looking with increased work of breathing
RR 26 afeb HR Irreg 130 BP 10070
Sat 90 RA
JVP 5cm
SOA ++
Displaced apex beat no cardiac murmurs 3rd heart sound present
Normal chest expansion but stony dull percussion in the bases (RgtL) bilateral inspiratory crepitations just above the dull areas
ECG ndash what is your diagnosis
Emergency Department HMO education series
2012
Cardiac failure
Emergency Department HMO education series
2012
Case C2 - Summary
Long standing heart failure with an acute
exacerbation due to new onset rapid AF
Treatment of AF amp heart failure
Antithrombotic strategy
Then rate control
Perhaps rhythm control
See review article re AF treatment
To be published early 2013 Australian Rural Doctor
Case D
Mid 60s male
Found SOB ++ in street
Ambulance called
In ED
SOB at rest
Doesnt want help
Funny smell
Further information
Dishevelled
HR 120 reg BP 9560 Sats 94 RA
Vomiting intermittently
What will you do
Further treatment and
investigation
Further history from patient and collateral
sources
Resuscitation
IV access fluids
Bloods ndash FBC UEC CMP Blood gas
pH 71 pCO2 20 pO2 90 HCO3 10 BE -16
Further treatment and
investigation
Further history from patient and collateral
sources
Resuscitation
IV access fluids
Bloods ndash FBC UEC CMP Blood gas
pH 71 pCO2 20 pO2 90 HCO3 10 BE -16
BSL gt30
Further treatment and
investigation
Treatment
IV fluids ndash caution with Na and cerebral oedema
IV insulin
001 ndash 01 unitskghr
aim for BSL 2mmolL drop per hour
Continue until metabolic correction
Monitor and correct K+ other electrolytes
Monitor urine ketones VBGABG
Identify precipitant
Resolution
Wife arrives and is relieved to find husband
Chairman of Rotary Club
UTI developed whilst wife away for weekend
Questions
Summary
Diagnosis of the breathless patient requires you to look for clueshellip The time course of the illness
Associated symptoms
Known diseases or risk factors for disease
Treatment of illnesses supported by evidence for pneumonia asthma PE AF etc
Interpretation of radiology best done with clinical context
Thankyou
Emergency Department HMO education series
2012
What else should I ask
Travel historyhellip
Other important symptoms of respiratory
disease
Cough
Acute
Chronic
Haemoptysis (cancer TB other infections)
Chest Pain
Daytime sleepiness (obstructive sleep apnea)
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Emergency Department HMO education series
2012
Exam amp investigationshellip
Unwell RR 36 T 368 HR 90 SR BP 180102
Satrsquos 88 RA
Evidence of work of breathing and use of accessory muscles (which are these)
Pursed lip breathing
Prolonged expiration with wheeze
ABG pH 728 pCO2 60 pO2 55 HCO3 26
What do these show
Do you want a CXR
Emergency Department HMO education series
2012
Emergency Department HMO education series
2012
Diagnosis
Acute cardiac failure ndash APO
Most likely cause
Treatment
ECG ndash filed unsigned and
unseen
Emergency Department HMO education series
2012
Diagnosis
Acute cardiac failure ndash APO
Most likely cause
Treatment
Emergency Department HMO education series
2012
Diagnosis - APO
Acute cardiac failure
Treatment
Medications Nitroglycerin SL topical or IV titrated to avoid hypotension Most rapidly
venodilates reduces LV afterload and corrects myocardial ischaemia
Frusemide IV Despite universal use absolute efficacy is unclear
Ventilatory Assistance Non-invasive ventilation (NIV) reduces mortality by 40 particularly with CPAP
and reduces need to intubate
Emergency Department HMO education series
2012
Case C2 - Male in 60rsquos
Progressive SOB over 6 months worse over 24 hours
Orthopnoea Paroxysmal nocturnal dyspnoea (PND) SOA All present to a minor degree over the 6 months but worse for 24 hours
Palpitations (last 24 hours)
Previous AMI 4 years ago pace maker
Ex-smoker Hypertension (HT) diabetes
Emergency Department HMO education series
2012
Examination
Unwell looking with increased work of breathing
RR 26 afeb HR Irreg 130 BP 10070
Sat 90 RA
JVP 5cm
SOA ++
Displaced apex beat no cardiac murmurs 3rd heart sound present
Normal chest expansion but stony dull percussion in the bases (RgtL) bilateral inspiratory crepitations just above the dull areas
ECG ndash what is your diagnosis
Emergency Department HMO education series
2012
Cardiac failure
Emergency Department HMO education series
2012
Case C2 - Summary
Long standing heart failure with an acute
exacerbation due to new onset rapid AF
Treatment of AF amp heart failure
Antithrombotic strategy
Then rate control
Perhaps rhythm control
See review article re AF treatment
To be published early 2013 Australian Rural Doctor
Case D
Mid 60s male
Found SOB ++ in street
Ambulance called
In ED
SOB at rest
Doesnt want help
Funny smell
Further information
Dishevelled
HR 120 reg BP 9560 Sats 94 RA
Vomiting intermittently
What will you do
Further treatment and
investigation
Further history from patient and collateral
sources
Resuscitation
IV access fluids
Bloods ndash FBC UEC CMP Blood gas
pH 71 pCO2 20 pO2 90 HCO3 10 BE -16
Further treatment and
investigation
Further history from patient and collateral
sources
Resuscitation
IV access fluids
Bloods ndash FBC UEC CMP Blood gas
pH 71 pCO2 20 pO2 90 HCO3 10 BE -16
BSL gt30
Further treatment and
investigation
Treatment
IV fluids ndash caution with Na and cerebral oedema
IV insulin
001 ndash 01 unitskghr
aim for BSL 2mmolL drop per hour
Continue until metabolic correction
Monitor and correct K+ other electrolytes
Monitor urine ketones VBGABG
Identify precipitant
Resolution
Wife arrives and is relieved to find husband
Chairman of Rotary Club
UTI developed whilst wife away for weekend
Questions
Summary
Diagnosis of the breathless patient requires you to look for clueshellip The time course of the illness
Associated symptoms
Known diseases or risk factors for disease
Treatment of illnesses supported by evidence for pneumonia asthma PE AF etc
Interpretation of radiology best done with clinical context
Thankyou
Emergency Department HMO education series
2012
What else should I ask
Travel historyhellip
Other important symptoms of respiratory
disease
Cough
Acute
Chronic
Haemoptysis (cancer TB other infections)
Chest Pain
Daytime sleepiness (obstructive sleep apnea)
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Emergency Department HMO education series
2012
Emergency Department HMO education series
2012
Diagnosis
Acute cardiac failure ndash APO
Most likely cause
Treatment
ECG ndash filed unsigned and
unseen
Emergency Department HMO education series
2012
Diagnosis
Acute cardiac failure ndash APO
Most likely cause
Treatment
Emergency Department HMO education series
2012
Diagnosis - APO
Acute cardiac failure
Treatment
Medications Nitroglycerin SL topical or IV titrated to avoid hypotension Most rapidly
venodilates reduces LV afterload and corrects myocardial ischaemia
Frusemide IV Despite universal use absolute efficacy is unclear
Ventilatory Assistance Non-invasive ventilation (NIV) reduces mortality by 40 particularly with CPAP
and reduces need to intubate
Emergency Department HMO education series
2012
Case C2 - Male in 60rsquos
Progressive SOB over 6 months worse over 24 hours
Orthopnoea Paroxysmal nocturnal dyspnoea (PND) SOA All present to a minor degree over the 6 months but worse for 24 hours
Palpitations (last 24 hours)
Previous AMI 4 years ago pace maker
Ex-smoker Hypertension (HT) diabetes
Emergency Department HMO education series
2012
Examination
Unwell looking with increased work of breathing
RR 26 afeb HR Irreg 130 BP 10070
Sat 90 RA
JVP 5cm
SOA ++
Displaced apex beat no cardiac murmurs 3rd heart sound present
Normal chest expansion but stony dull percussion in the bases (RgtL) bilateral inspiratory crepitations just above the dull areas
ECG ndash what is your diagnosis
Emergency Department HMO education series
2012
Cardiac failure
Emergency Department HMO education series
2012
Case C2 - Summary
Long standing heart failure with an acute
exacerbation due to new onset rapid AF
Treatment of AF amp heart failure
Antithrombotic strategy
Then rate control
Perhaps rhythm control
See review article re AF treatment
To be published early 2013 Australian Rural Doctor
Case D
Mid 60s male
Found SOB ++ in street
Ambulance called
In ED
SOB at rest
Doesnt want help
Funny smell
Further information
Dishevelled
HR 120 reg BP 9560 Sats 94 RA
Vomiting intermittently
What will you do
Further treatment and
investigation
Further history from patient and collateral
sources
Resuscitation
IV access fluids
Bloods ndash FBC UEC CMP Blood gas
pH 71 pCO2 20 pO2 90 HCO3 10 BE -16
Further treatment and
investigation
Further history from patient and collateral
sources
Resuscitation
IV access fluids
Bloods ndash FBC UEC CMP Blood gas
pH 71 pCO2 20 pO2 90 HCO3 10 BE -16
BSL gt30
Further treatment and
investigation
Treatment
IV fluids ndash caution with Na and cerebral oedema
IV insulin
001 ndash 01 unitskghr
aim for BSL 2mmolL drop per hour
Continue until metabolic correction
Monitor and correct K+ other electrolytes
Monitor urine ketones VBGABG
Identify precipitant
Resolution
Wife arrives and is relieved to find husband
Chairman of Rotary Club
UTI developed whilst wife away for weekend
Questions
Summary
Diagnosis of the breathless patient requires you to look for clueshellip The time course of the illness
Associated symptoms
Known diseases or risk factors for disease
Treatment of illnesses supported by evidence for pneumonia asthma PE AF etc
Interpretation of radiology best done with clinical context
Thankyou
Emergency Department HMO education series
2012
What else should I ask
Travel historyhellip
Other important symptoms of respiratory
disease
Cough
Acute
Chronic
Haemoptysis (cancer TB other infections)
Chest Pain
Daytime sleepiness (obstructive sleep apnea)
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Emergency Department HMO education series
2012
Diagnosis
Acute cardiac failure ndash APO
Most likely cause
Treatment
ECG ndash filed unsigned and
unseen
Emergency Department HMO education series
2012
Diagnosis
Acute cardiac failure ndash APO
Most likely cause
Treatment
Emergency Department HMO education series
2012
Diagnosis - APO
Acute cardiac failure
Treatment
Medications Nitroglycerin SL topical or IV titrated to avoid hypotension Most rapidly
venodilates reduces LV afterload and corrects myocardial ischaemia
Frusemide IV Despite universal use absolute efficacy is unclear
Ventilatory Assistance Non-invasive ventilation (NIV) reduces mortality by 40 particularly with CPAP
and reduces need to intubate
Emergency Department HMO education series
2012
Case C2 - Male in 60rsquos
Progressive SOB over 6 months worse over 24 hours
Orthopnoea Paroxysmal nocturnal dyspnoea (PND) SOA All present to a minor degree over the 6 months but worse for 24 hours
Palpitations (last 24 hours)
Previous AMI 4 years ago pace maker
Ex-smoker Hypertension (HT) diabetes
Emergency Department HMO education series
2012
Examination
Unwell looking with increased work of breathing
RR 26 afeb HR Irreg 130 BP 10070
Sat 90 RA
JVP 5cm
SOA ++
Displaced apex beat no cardiac murmurs 3rd heart sound present
Normal chest expansion but stony dull percussion in the bases (RgtL) bilateral inspiratory crepitations just above the dull areas
ECG ndash what is your diagnosis
Emergency Department HMO education series
2012
Cardiac failure
Emergency Department HMO education series
2012
Case C2 - Summary
Long standing heart failure with an acute
exacerbation due to new onset rapid AF
Treatment of AF amp heart failure
Antithrombotic strategy
Then rate control
Perhaps rhythm control
See review article re AF treatment
To be published early 2013 Australian Rural Doctor
Case D
Mid 60s male
Found SOB ++ in street
Ambulance called
In ED
SOB at rest
Doesnt want help
Funny smell
Further information
Dishevelled
HR 120 reg BP 9560 Sats 94 RA
Vomiting intermittently
What will you do
Further treatment and
investigation
Further history from patient and collateral
sources
Resuscitation
IV access fluids
Bloods ndash FBC UEC CMP Blood gas
pH 71 pCO2 20 pO2 90 HCO3 10 BE -16
Further treatment and
investigation
Further history from patient and collateral
sources
Resuscitation
IV access fluids
Bloods ndash FBC UEC CMP Blood gas
pH 71 pCO2 20 pO2 90 HCO3 10 BE -16
BSL gt30
Further treatment and
investigation
Treatment
IV fluids ndash caution with Na and cerebral oedema
IV insulin
001 ndash 01 unitskghr
aim for BSL 2mmolL drop per hour
Continue until metabolic correction
Monitor and correct K+ other electrolytes
Monitor urine ketones VBGABG
Identify precipitant
Resolution
Wife arrives and is relieved to find husband
Chairman of Rotary Club
UTI developed whilst wife away for weekend
Questions
Summary
Diagnosis of the breathless patient requires you to look for clueshellip The time course of the illness
Associated symptoms
Known diseases or risk factors for disease
Treatment of illnesses supported by evidence for pneumonia asthma PE AF etc
Interpretation of radiology best done with clinical context
Thankyou
Emergency Department HMO education series
2012
What else should I ask
Travel historyhellip
Other important symptoms of respiratory
disease
Cough
Acute
Chronic
Haemoptysis (cancer TB other infections)
Chest Pain
Daytime sleepiness (obstructive sleep apnea)
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
ECG ndash filed unsigned and
unseen
Emergency Department HMO education series
2012
Diagnosis
Acute cardiac failure ndash APO
Most likely cause
Treatment
Emergency Department HMO education series
2012
Diagnosis - APO
Acute cardiac failure
Treatment
Medications Nitroglycerin SL topical or IV titrated to avoid hypotension Most rapidly
venodilates reduces LV afterload and corrects myocardial ischaemia
Frusemide IV Despite universal use absolute efficacy is unclear
Ventilatory Assistance Non-invasive ventilation (NIV) reduces mortality by 40 particularly with CPAP
and reduces need to intubate
Emergency Department HMO education series
2012
Case C2 - Male in 60rsquos
Progressive SOB over 6 months worse over 24 hours
Orthopnoea Paroxysmal nocturnal dyspnoea (PND) SOA All present to a minor degree over the 6 months but worse for 24 hours
Palpitations (last 24 hours)
Previous AMI 4 years ago pace maker
Ex-smoker Hypertension (HT) diabetes
Emergency Department HMO education series
2012
Examination
Unwell looking with increased work of breathing
RR 26 afeb HR Irreg 130 BP 10070
Sat 90 RA
JVP 5cm
SOA ++
Displaced apex beat no cardiac murmurs 3rd heart sound present
Normal chest expansion but stony dull percussion in the bases (RgtL) bilateral inspiratory crepitations just above the dull areas
ECG ndash what is your diagnosis
Emergency Department HMO education series
2012
Cardiac failure
Emergency Department HMO education series
2012
Case C2 - Summary
Long standing heart failure with an acute
exacerbation due to new onset rapid AF
Treatment of AF amp heart failure
Antithrombotic strategy
Then rate control
Perhaps rhythm control
See review article re AF treatment
To be published early 2013 Australian Rural Doctor
Case D
Mid 60s male
Found SOB ++ in street
Ambulance called
In ED
SOB at rest
Doesnt want help
Funny smell
Further information
Dishevelled
HR 120 reg BP 9560 Sats 94 RA
Vomiting intermittently
What will you do
Further treatment and
investigation
Further history from patient and collateral
sources
Resuscitation
IV access fluids
Bloods ndash FBC UEC CMP Blood gas
pH 71 pCO2 20 pO2 90 HCO3 10 BE -16
Further treatment and
investigation
Further history from patient and collateral
sources
Resuscitation
IV access fluids
Bloods ndash FBC UEC CMP Blood gas
pH 71 pCO2 20 pO2 90 HCO3 10 BE -16
BSL gt30
Further treatment and
investigation
Treatment
IV fluids ndash caution with Na and cerebral oedema
IV insulin
001 ndash 01 unitskghr
aim for BSL 2mmolL drop per hour
Continue until metabolic correction
Monitor and correct K+ other electrolytes
Monitor urine ketones VBGABG
Identify precipitant
Resolution
Wife arrives and is relieved to find husband
Chairman of Rotary Club
UTI developed whilst wife away for weekend
Questions
Summary
Diagnosis of the breathless patient requires you to look for clueshellip The time course of the illness
Associated symptoms
Known diseases or risk factors for disease
Treatment of illnesses supported by evidence for pneumonia asthma PE AF etc
Interpretation of radiology best done with clinical context
Thankyou
Emergency Department HMO education series
2012
What else should I ask
Travel historyhellip
Other important symptoms of respiratory
disease
Cough
Acute
Chronic
Haemoptysis (cancer TB other infections)
Chest Pain
Daytime sleepiness (obstructive sleep apnea)
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Emergency Department HMO education series
2012
Diagnosis
Acute cardiac failure ndash APO
Most likely cause
Treatment
Emergency Department HMO education series
2012
Diagnosis - APO
Acute cardiac failure
Treatment
Medications Nitroglycerin SL topical or IV titrated to avoid hypotension Most rapidly
venodilates reduces LV afterload and corrects myocardial ischaemia
Frusemide IV Despite universal use absolute efficacy is unclear
Ventilatory Assistance Non-invasive ventilation (NIV) reduces mortality by 40 particularly with CPAP
and reduces need to intubate
Emergency Department HMO education series
2012
Case C2 - Male in 60rsquos
Progressive SOB over 6 months worse over 24 hours
Orthopnoea Paroxysmal nocturnal dyspnoea (PND) SOA All present to a minor degree over the 6 months but worse for 24 hours
Palpitations (last 24 hours)
Previous AMI 4 years ago pace maker
Ex-smoker Hypertension (HT) diabetes
Emergency Department HMO education series
2012
Examination
Unwell looking with increased work of breathing
RR 26 afeb HR Irreg 130 BP 10070
Sat 90 RA
JVP 5cm
SOA ++
Displaced apex beat no cardiac murmurs 3rd heart sound present
Normal chest expansion but stony dull percussion in the bases (RgtL) bilateral inspiratory crepitations just above the dull areas
ECG ndash what is your diagnosis
Emergency Department HMO education series
2012
Cardiac failure
Emergency Department HMO education series
2012
Case C2 - Summary
Long standing heart failure with an acute
exacerbation due to new onset rapid AF
Treatment of AF amp heart failure
Antithrombotic strategy
Then rate control
Perhaps rhythm control
See review article re AF treatment
To be published early 2013 Australian Rural Doctor
Case D
Mid 60s male
Found SOB ++ in street
Ambulance called
In ED
SOB at rest
Doesnt want help
Funny smell
Further information
Dishevelled
HR 120 reg BP 9560 Sats 94 RA
Vomiting intermittently
What will you do
Further treatment and
investigation
Further history from patient and collateral
sources
Resuscitation
IV access fluids
Bloods ndash FBC UEC CMP Blood gas
pH 71 pCO2 20 pO2 90 HCO3 10 BE -16
Further treatment and
investigation
Further history from patient and collateral
sources
Resuscitation
IV access fluids
Bloods ndash FBC UEC CMP Blood gas
pH 71 pCO2 20 pO2 90 HCO3 10 BE -16
BSL gt30
Further treatment and
investigation
Treatment
IV fluids ndash caution with Na and cerebral oedema
IV insulin
001 ndash 01 unitskghr
aim for BSL 2mmolL drop per hour
Continue until metabolic correction
Monitor and correct K+ other electrolytes
Monitor urine ketones VBGABG
Identify precipitant
Resolution
Wife arrives and is relieved to find husband
Chairman of Rotary Club
UTI developed whilst wife away for weekend
Questions
Summary
Diagnosis of the breathless patient requires you to look for clueshellip The time course of the illness
Associated symptoms
Known diseases or risk factors for disease
Treatment of illnesses supported by evidence for pneumonia asthma PE AF etc
Interpretation of radiology best done with clinical context
Thankyou
Emergency Department HMO education series
2012
What else should I ask
Travel historyhellip
Other important symptoms of respiratory
disease
Cough
Acute
Chronic
Haemoptysis (cancer TB other infections)
Chest Pain
Daytime sleepiness (obstructive sleep apnea)
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Emergency Department HMO education series
2012
Diagnosis - APO
Acute cardiac failure
Treatment
Medications Nitroglycerin SL topical or IV titrated to avoid hypotension Most rapidly
venodilates reduces LV afterload and corrects myocardial ischaemia
Frusemide IV Despite universal use absolute efficacy is unclear
Ventilatory Assistance Non-invasive ventilation (NIV) reduces mortality by 40 particularly with CPAP
and reduces need to intubate
Emergency Department HMO education series
2012
Case C2 - Male in 60rsquos
Progressive SOB over 6 months worse over 24 hours
Orthopnoea Paroxysmal nocturnal dyspnoea (PND) SOA All present to a minor degree over the 6 months but worse for 24 hours
Palpitations (last 24 hours)
Previous AMI 4 years ago pace maker
Ex-smoker Hypertension (HT) diabetes
Emergency Department HMO education series
2012
Examination
Unwell looking with increased work of breathing
RR 26 afeb HR Irreg 130 BP 10070
Sat 90 RA
JVP 5cm
SOA ++
Displaced apex beat no cardiac murmurs 3rd heart sound present
Normal chest expansion but stony dull percussion in the bases (RgtL) bilateral inspiratory crepitations just above the dull areas
ECG ndash what is your diagnosis
Emergency Department HMO education series
2012
Cardiac failure
Emergency Department HMO education series
2012
Case C2 - Summary
Long standing heart failure with an acute
exacerbation due to new onset rapid AF
Treatment of AF amp heart failure
Antithrombotic strategy
Then rate control
Perhaps rhythm control
See review article re AF treatment
To be published early 2013 Australian Rural Doctor
Case D
Mid 60s male
Found SOB ++ in street
Ambulance called
In ED
SOB at rest
Doesnt want help
Funny smell
Further information
Dishevelled
HR 120 reg BP 9560 Sats 94 RA
Vomiting intermittently
What will you do
Further treatment and
investigation
Further history from patient and collateral
sources
Resuscitation
IV access fluids
Bloods ndash FBC UEC CMP Blood gas
pH 71 pCO2 20 pO2 90 HCO3 10 BE -16
Further treatment and
investigation
Further history from patient and collateral
sources
Resuscitation
IV access fluids
Bloods ndash FBC UEC CMP Blood gas
pH 71 pCO2 20 pO2 90 HCO3 10 BE -16
BSL gt30
Further treatment and
investigation
Treatment
IV fluids ndash caution with Na and cerebral oedema
IV insulin
001 ndash 01 unitskghr
aim for BSL 2mmolL drop per hour
Continue until metabolic correction
Monitor and correct K+ other electrolytes
Monitor urine ketones VBGABG
Identify precipitant
Resolution
Wife arrives and is relieved to find husband
Chairman of Rotary Club
UTI developed whilst wife away for weekend
Questions
Summary
Diagnosis of the breathless patient requires you to look for clueshellip The time course of the illness
Associated symptoms
Known diseases or risk factors for disease
Treatment of illnesses supported by evidence for pneumonia asthma PE AF etc
Interpretation of radiology best done with clinical context
Thankyou
Emergency Department HMO education series
2012
What else should I ask
Travel historyhellip
Other important symptoms of respiratory
disease
Cough
Acute
Chronic
Haemoptysis (cancer TB other infections)
Chest Pain
Daytime sleepiness (obstructive sleep apnea)
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Emergency Department HMO education series
2012
Case C2 - Male in 60rsquos
Progressive SOB over 6 months worse over 24 hours
Orthopnoea Paroxysmal nocturnal dyspnoea (PND) SOA All present to a minor degree over the 6 months but worse for 24 hours
Palpitations (last 24 hours)
Previous AMI 4 years ago pace maker
Ex-smoker Hypertension (HT) diabetes
Emergency Department HMO education series
2012
Examination
Unwell looking with increased work of breathing
RR 26 afeb HR Irreg 130 BP 10070
Sat 90 RA
JVP 5cm
SOA ++
Displaced apex beat no cardiac murmurs 3rd heart sound present
Normal chest expansion but stony dull percussion in the bases (RgtL) bilateral inspiratory crepitations just above the dull areas
ECG ndash what is your diagnosis
Emergency Department HMO education series
2012
Cardiac failure
Emergency Department HMO education series
2012
Case C2 - Summary
Long standing heart failure with an acute
exacerbation due to new onset rapid AF
Treatment of AF amp heart failure
Antithrombotic strategy
Then rate control
Perhaps rhythm control
See review article re AF treatment
To be published early 2013 Australian Rural Doctor
Case D
Mid 60s male
Found SOB ++ in street
Ambulance called
In ED
SOB at rest
Doesnt want help
Funny smell
Further information
Dishevelled
HR 120 reg BP 9560 Sats 94 RA
Vomiting intermittently
What will you do
Further treatment and
investigation
Further history from patient and collateral
sources
Resuscitation
IV access fluids
Bloods ndash FBC UEC CMP Blood gas
pH 71 pCO2 20 pO2 90 HCO3 10 BE -16
Further treatment and
investigation
Further history from patient and collateral
sources
Resuscitation
IV access fluids
Bloods ndash FBC UEC CMP Blood gas
pH 71 pCO2 20 pO2 90 HCO3 10 BE -16
BSL gt30
Further treatment and
investigation
Treatment
IV fluids ndash caution with Na and cerebral oedema
IV insulin
001 ndash 01 unitskghr
aim for BSL 2mmolL drop per hour
Continue until metabolic correction
Monitor and correct K+ other electrolytes
Monitor urine ketones VBGABG
Identify precipitant
Resolution
Wife arrives and is relieved to find husband
Chairman of Rotary Club
UTI developed whilst wife away for weekend
Questions
Summary
Diagnosis of the breathless patient requires you to look for clueshellip The time course of the illness
Associated symptoms
Known diseases or risk factors for disease
Treatment of illnesses supported by evidence for pneumonia asthma PE AF etc
Interpretation of radiology best done with clinical context
Thankyou
Emergency Department HMO education series
2012
What else should I ask
Travel historyhellip
Other important symptoms of respiratory
disease
Cough
Acute
Chronic
Haemoptysis (cancer TB other infections)
Chest Pain
Daytime sleepiness (obstructive sleep apnea)
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Emergency Department HMO education series
2012
Examination
Unwell looking with increased work of breathing
RR 26 afeb HR Irreg 130 BP 10070
Sat 90 RA
JVP 5cm
SOA ++
Displaced apex beat no cardiac murmurs 3rd heart sound present
Normal chest expansion but stony dull percussion in the bases (RgtL) bilateral inspiratory crepitations just above the dull areas
ECG ndash what is your diagnosis
Emergency Department HMO education series
2012
Cardiac failure
Emergency Department HMO education series
2012
Case C2 - Summary
Long standing heart failure with an acute
exacerbation due to new onset rapid AF
Treatment of AF amp heart failure
Antithrombotic strategy
Then rate control
Perhaps rhythm control
See review article re AF treatment
To be published early 2013 Australian Rural Doctor
Case D
Mid 60s male
Found SOB ++ in street
Ambulance called
In ED
SOB at rest
Doesnt want help
Funny smell
Further information
Dishevelled
HR 120 reg BP 9560 Sats 94 RA
Vomiting intermittently
What will you do
Further treatment and
investigation
Further history from patient and collateral
sources
Resuscitation
IV access fluids
Bloods ndash FBC UEC CMP Blood gas
pH 71 pCO2 20 pO2 90 HCO3 10 BE -16
Further treatment and
investigation
Further history from patient and collateral
sources
Resuscitation
IV access fluids
Bloods ndash FBC UEC CMP Blood gas
pH 71 pCO2 20 pO2 90 HCO3 10 BE -16
BSL gt30
Further treatment and
investigation
Treatment
IV fluids ndash caution with Na and cerebral oedema
IV insulin
001 ndash 01 unitskghr
aim for BSL 2mmolL drop per hour
Continue until metabolic correction
Monitor and correct K+ other electrolytes
Monitor urine ketones VBGABG
Identify precipitant
Resolution
Wife arrives and is relieved to find husband
Chairman of Rotary Club
UTI developed whilst wife away for weekend
Questions
Summary
Diagnosis of the breathless patient requires you to look for clueshellip The time course of the illness
Associated symptoms
Known diseases or risk factors for disease
Treatment of illnesses supported by evidence for pneumonia asthma PE AF etc
Interpretation of radiology best done with clinical context
Thankyou
Emergency Department HMO education series
2012
What else should I ask
Travel historyhellip
Other important symptoms of respiratory
disease
Cough
Acute
Chronic
Haemoptysis (cancer TB other infections)
Chest Pain
Daytime sleepiness (obstructive sleep apnea)
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
ECG ndash what is your diagnosis
Emergency Department HMO education series
2012
Cardiac failure
Emergency Department HMO education series
2012
Case C2 - Summary
Long standing heart failure with an acute
exacerbation due to new onset rapid AF
Treatment of AF amp heart failure
Antithrombotic strategy
Then rate control
Perhaps rhythm control
See review article re AF treatment
To be published early 2013 Australian Rural Doctor
Case D
Mid 60s male
Found SOB ++ in street
Ambulance called
In ED
SOB at rest
Doesnt want help
Funny smell
Further information
Dishevelled
HR 120 reg BP 9560 Sats 94 RA
Vomiting intermittently
What will you do
Further treatment and
investigation
Further history from patient and collateral
sources
Resuscitation
IV access fluids
Bloods ndash FBC UEC CMP Blood gas
pH 71 pCO2 20 pO2 90 HCO3 10 BE -16
Further treatment and
investigation
Further history from patient and collateral
sources
Resuscitation
IV access fluids
Bloods ndash FBC UEC CMP Blood gas
pH 71 pCO2 20 pO2 90 HCO3 10 BE -16
BSL gt30
Further treatment and
investigation
Treatment
IV fluids ndash caution with Na and cerebral oedema
IV insulin
001 ndash 01 unitskghr
aim for BSL 2mmolL drop per hour
Continue until metabolic correction
Monitor and correct K+ other electrolytes
Monitor urine ketones VBGABG
Identify precipitant
Resolution
Wife arrives and is relieved to find husband
Chairman of Rotary Club
UTI developed whilst wife away for weekend
Questions
Summary
Diagnosis of the breathless patient requires you to look for clueshellip The time course of the illness
Associated symptoms
Known diseases or risk factors for disease
Treatment of illnesses supported by evidence for pneumonia asthma PE AF etc
Interpretation of radiology best done with clinical context
Thankyou
Emergency Department HMO education series
2012
What else should I ask
Travel historyhellip
Other important symptoms of respiratory
disease
Cough
Acute
Chronic
Haemoptysis (cancer TB other infections)
Chest Pain
Daytime sleepiness (obstructive sleep apnea)
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Emergency Department HMO education series
2012
Cardiac failure
Emergency Department HMO education series
2012
Case C2 - Summary
Long standing heart failure with an acute
exacerbation due to new onset rapid AF
Treatment of AF amp heart failure
Antithrombotic strategy
Then rate control
Perhaps rhythm control
See review article re AF treatment
To be published early 2013 Australian Rural Doctor
Case D
Mid 60s male
Found SOB ++ in street
Ambulance called
In ED
SOB at rest
Doesnt want help
Funny smell
Further information
Dishevelled
HR 120 reg BP 9560 Sats 94 RA
Vomiting intermittently
What will you do
Further treatment and
investigation
Further history from patient and collateral
sources
Resuscitation
IV access fluids
Bloods ndash FBC UEC CMP Blood gas
pH 71 pCO2 20 pO2 90 HCO3 10 BE -16
Further treatment and
investigation
Further history from patient and collateral
sources
Resuscitation
IV access fluids
Bloods ndash FBC UEC CMP Blood gas
pH 71 pCO2 20 pO2 90 HCO3 10 BE -16
BSL gt30
Further treatment and
investigation
Treatment
IV fluids ndash caution with Na and cerebral oedema
IV insulin
001 ndash 01 unitskghr
aim for BSL 2mmolL drop per hour
Continue until metabolic correction
Monitor and correct K+ other electrolytes
Monitor urine ketones VBGABG
Identify precipitant
Resolution
Wife arrives and is relieved to find husband
Chairman of Rotary Club
UTI developed whilst wife away for weekend
Questions
Summary
Diagnosis of the breathless patient requires you to look for clueshellip The time course of the illness
Associated symptoms
Known diseases or risk factors for disease
Treatment of illnesses supported by evidence for pneumonia asthma PE AF etc
Interpretation of radiology best done with clinical context
Thankyou
Emergency Department HMO education series
2012
What else should I ask
Travel historyhellip
Other important symptoms of respiratory
disease
Cough
Acute
Chronic
Haemoptysis (cancer TB other infections)
Chest Pain
Daytime sleepiness (obstructive sleep apnea)
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Emergency Department HMO education series
2012
Case C2 - Summary
Long standing heart failure with an acute
exacerbation due to new onset rapid AF
Treatment of AF amp heart failure
Antithrombotic strategy
Then rate control
Perhaps rhythm control
See review article re AF treatment
To be published early 2013 Australian Rural Doctor
Case D
Mid 60s male
Found SOB ++ in street
Ambulance called
In ED
SOB at rest
Doesnt want help
Funny smell
Further information
Dishevelled
HR 120 reg BP 9560 Sats 94 RA
Vomiting intermittently
What will you do
Further treatment and
investigation
Further history from patient and collateral
sources
Resuscitation
IV access fluids
Bloods ndash FBC UEC CMP Blood gas
pH 71 pCO2 20 pO2 90 HCO3 10 BE -16
Further treatment and
investigation
Further history from patient and collateral
sources
Resuscitation
IV access fluids
Bloods ndash FBC UEC CMP Blood gas
pH 71 pCO2 20 pO2 90 HCO3 10 BE -16
BSL gt30
Further treatment and
investigation
Treatment
IV fluids ndash caution with Na and cerebral oedema
IV insulin
001 ndash 01 unitskghr
aim for BSL 2mmolL drop per hour
Continue until metabolic correction
Monitor and correct K+ other electrolytes
Monitor urine ketones VBGABG
Identify precipitant
Resolution
Wife arrives and is relieved to find husband
Chairman of Rotary Club
UTI developed whilst wife away for weekend
Questions
Summary
Diagnosis of the breathless patient requires you to look for clueshellip The time course of the illness
Associated symptoms
Known diseases or risk factors for disease
Treatment of illnesses supported by evidence for pneumonia asthma PE AF etc
Interpretation of radiology best done with clinical context
Thankyou
Emergency Department HMO education series
2012
What else should I ask
Travel historyhellip
Other important symptoms of respiratory
disease
Cough
Acute
Chronic
Haemoptysis (cancer TB other infections)
Chest Pain
Daytime sleepiness (obstructive sleep apnea)
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Case D
Mid 60s male
Found SOB ++ in street
Ambulance called
In ED
SOB at rest
Doesnt want help
Funny smell
Further information
Dishevelled
HR 120 reg BP 9560 Sats 94 RA
Vomiting intermittently
What will you do
Further treatment and
investigation
Further history from patient and collateral
sources
Resuscitation
IV access fluids
Bloods ndash FBC UEC CMP Blood gas
pH 71 pCO2 20 pO2 90 HCO3 10 BE -16
Further treatment and
investigation
Further history from patient and collateral
sources
Resuscitation
IV access fluids
Bloods ndash FBC UEC CMP Blood gas
pH 71 pCO2 20 pO2 90 HCO3 10 BE -16
BSL gt30
Further treatment and
investigation
Treatment
IV fluids ndash caution with Na and cerebral oedema
IV insulin
001 ndash 01 unitskghr
aim for BSL 2mmolL drop per hour
Continue until metabolic correction
Monitor and correct K+ other electrolytes
Monitor urine ketones VBGABG
Identify precipitant
Resolution
Wife arrives and is relieved to find husband
Chairman of Rotary Club
UTI developed whilst wife away for weekend
Questions
Summary
Diagnosis of the breathless patient requires you to look for clueshellip The time course of the illness
Associated symptoms
Known diseases or risk factors for disease
Treatment of illnesses supported by evidence for pneumonia asthma PE AF etc
Interpretation of radiology best done with clinical context
Thankyou
Emergency Department HMO education series
2012
What else should I ask
Travel historyhellip
Other important symptoms of respiratory
disease
Cough
Acute
Chronic
Haemoptysis (cancer TB other infections)
Chest Pain
Daytime sleepiness (obstructive sleep apnea)
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Further information
Dishevelled
HR 120 reg BP 9560 Sats 94 RA
Vomiting intermittently
What will you do
Further treatment and
investigation
Further history from patient and collateral
sources
Resuscitation
IV access fluids
Bloods ndash FBC UEC CMP Blood gas
pH 71 pCO2 20 pO2 90 HCO3 10 BE -16
Further treatment and
investigation
Further history from patient and collateral
sources
Resuscitation
IV access fluids
Bloods ndash FBC UEC CMP Blood gas
pH 71 pCO2 20 pO2 90 HCO3 10 BE -16
BSL gt30
Further treatment and
investigation
Treatment
IV fluids ndash caution with Na and cerebral oedema
IV insulin
001 ndash 01 unitskghr
aim for BSL 2mmolL drop per hour
Continue until metabolic correction
Monitor and correct K+ other electrolytes
Monitor urine ketones VBGABG
Identify precipitant
Resolution
Wife arrives and is relieved to find husband
Chairman of Rotary Club
UTI developed whilst wife away for weekend
Questions
Summary
Diagnosis of the breathless patient requires you to look for clueshellip The time course of the illness
Associated symptoms
Known diseases or risk factors for disease
Treatment of illnesses supported by evidence for pneumonia asthma PE AF etc
Interpretation of radiology best done with clinical context
Thankyou
Emergency Department HMO education series
2012
What else should I ask
Travel historyhellip
Other important symptoms of respiratory
disease
Cough
Acute
Chronic
Haemoptysis (cancer TB other infections)
Chest Pain
Daytime sleepiness (obstructive sleep apnea)
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Further treatment and
investigation
Further history from patient and collateral
sources
Resuscitation
IV access fluids
Bloods ndash FBC UEC CMP Blood gas
pH 71 pCO2 20 pO2 90 HCO3 10 BE -16
Further treatment and
investigation
Further history from patient and collateral
sources
Resuscitation
IV access fluids
Bloods ndash FBC UEC CMP Blood gas
pH 71 pCO2 20 pO2 90 HCO3 10 BE -16
BSL gt30
Further treatment and
investigation
Treatment
IV fluids ndash caution with Na and cerebral oedema
IV insulin
001 ndash 01 unitskghr
aim for BSL 2mmolL drop per hour
Continue until metabolic correction
Monitor and correct K+ other electrolytes
Monitor urine ketones VBGABG
Identify precipitant
Resolution
Wife arrives and is relieved to find husband
Chairman of Rotary Club
UTI developed whilst wife away for weekend
Questions
Summary
Diagnosis of the breathless patient requires you to look for clueshellip The time course of the illness
Associated symptoms
Known diseases or risk factors for disease
Treatment of illnesses supported by evidence for pneumonia asthma PE AF etc
Interpretation of radiology best done with clinical context
Thankyou
Emergency Department HMO education series
2012
What else should I ask
Travel historyhellip
Other important symptoms of respiratory
disease
Cough
Acute
Chronic
Haemoptysis (cancer TB other infections)
Chest Pain
Daytime sleepiness (obstructive sleep apnea)
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Further treatment and
investigation
Further history from patient and collateral
sources
Resuscitation
IV access fluids
Bloods ndash FBC UEC CMP Blood gas
pH 71 pCO2 20 pO2 90 HCO3 10 BE -16
BSL gt30
Further treatment and
investigation
Treatment
IV fluids ndash caution with Na and cerebral oedema
IV insulin
001 ndash 01 unitskghr
aim for BSL 2mmolL drop per hour
Continue until metabolic correction
Monitor and correct K+ other electrolytes
Monitor urine ketones VBGABG
Identify precipitant
Resolution
Wife arrives and is relieved to find husband
Chairman of Rotary Club
UTI developed whilst wife away for weekend
Questions
Summary
Diagnosis of the breathless patient requires you to look for clueshellip The time course of the illness
Associated symptoms
Known diseases or risk factors for disease
Treatment of illnesses supported by evidence for pneumonia asthma PE AF etc
Interpretation of radiology best done with clinical context
Thankyou
Emergency Department HMO education series
2012
What else should I ask
Travel historyhellip
Other important symptoms of respiratory
disease
Cough
Acute
Chronic
Haemoptysis (cancer TB other infections)
Chest Pain
Daytime sleepiness (obstructive sleep apnea)
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Further treatment and
investigation
Treatment
IV fluids ndash caution with Na and cerebral oedema
IV insulin
001 ndash 01 unitskghr
aim for BSL 2mmolL drop per hour
Continue until metabolic correction
Monitor and correct K+ other electrolytes
Monitor urine ketones VBGABG
Identify precipitant
Resolution
Wife arrives and is relieved to find husband
Chairman of Rotary Club
UTI developed whilst wife away for weekend
Questions
Summary
Diagnosis of the breathless patient requires you to look for clueshellip The time course of the illness
Associated symptoms
Known diseases or risk factors for disease
Treatment of illnesses supported by evidence for pneumonia asthma PE AF etc
Interpretation of radiology best done with clinical context
Thankyou
Emergency Department HMO education series
2012
What else should I ask
Travel historyhellip
Other important symptoms of respiratory
disease
Cough
Acute
Chronic
Haemoptysis (cancer TB other infections)
Chest Pain
Daytime sleepiness (obstructive sleep apnea)
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Resolution
Wife arrives and is relieved to find husband
Chairman of Rotary Club
UTI developed whilst wife away for weekend
Questions
Summary
Diagnosis of the breathless patient requires you to look for clueshellip The time course of the illness
Associated symptoms
Known diseases or risk factors for disease
Treatment of illnesses supported by evidence for pneumonia asthma PE AF etc
Interpretation of radiology best done with clinical context
Thankyou
Emergency Department HMO education series
2012
What else should I ask
Travel historyhellip
Other important symptoms of respiratory
disease
Cough
Acute
Chronic
Haemoptysis (cancer TB other infections)
Chest Pain
Daytime sleepiness (obstructive sleep apnea)
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Questions
Summary
Diagnosis of the breathless patient requires you to look for clueshellip The time course of the illness
Associated symptoms
Known diseases or risk factors for disease
Treatment of illnesses supported by evidence for pneumonia asthma PE AF etc
Interpretation of radiology best done with clinical context
Thankyou
Emergency Department HMO education series
2012
What else should I ask
Travel historyhellip
Other important symptoms of respiratory
disease
Cough
Acute
Chronic
Haemoptysis (cancer TB other infections)
Chest Pain
Daytime sleepiness (obstructive sleep apnea)
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Summary
Diagnosis of the breathless patient requires you to look for clueshellip The time course of the illness
Associated symptoms
Known diseases or risk factors for disease
Treatment of illnesses supported by evidence for pneumonia asthma PE AF etc
Interpretation of radiology best done with clinical context
Thankyou
Emergency Department HMO education series
2012
What else should I ask
Travel historyhellip
Other important symptoms of respiratory
disease
Cough
Acute
Chronic
Haemoptysis (cancer TB other infections)
Chest Pain
Daytime sleepiness (obstructive sleep apnea)
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Thankyou
Emergency Department HMO education series
2012
What else should I ask
Travel historyhellip
Other important symptoms of respiratory
disease
Cough
Acute
Chronic
Haemoptysis (cancer TB other infections)
Chest Pain
Daytime sleepiness (obstructive sleep apnea)
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Emergency Department HMO education series
2012
What else should I ask
Travel historyhellip
Other important symptoms of respiratory
disease
Cough
Acute
Chronic
Haemoptysis (cancer TB other infections)
Chest Pain
Daytime sleepiness (obstructive sleep apnea)
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
Image gallery ndash eg radiology First slide with image question
