CLINICAL PROBLEM SOLVING WHEN YOURE ON CALL Speaker: Connie Tomada, MD.

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CLINICAL PROBLEM SOLVING WHEN YOU’RE ON CALL Speaker: Connie Tomada, MD

Transcript of CLINICAL PROBLEM SOLVING WHEN YOURE ON CALL Speaker: Connie Tomada, MD.

Page 1: CLINICAL PROBLEM SOLVING WHEN YOURE ON CALL Speaker: Connie Tomada, MD.

CLINICAL PROBLEM SOLVING WHEN YOU’RE

ON CALL

CLINICAL PROBLEM SOLVING WHEN YOU’RE

ON CALLSpeaker: Connie Tomada, MDSpeaker: Connie Tomada, MD

Page 2: CLINICAL PROBLEM SOLVING WHEN YOURE ON CALL Speaker: Connie Tomada, MD.

CLINICAL PROBLEM SOLVING WHEN YOU’RE

ON CALL

CLINICAL PROBLEM SOLVING WHEN YOU’RE

ON CALLHow to work-up and manage

Shortness of BreathHow to work-up and manage

Shortness of Breath

Page 3: CLINICAL PROBLEM SOLVING WHEN YOURE ON CALL Speaker: Connie Tomada, MD.

Shortness of BreathShortness of Breath

Cardiovascular CHF, PE

PulmonaryPneumonia, asthma,

COPD

Others anxiety, upper airway obstruction, ascites

Life-threatening hypoxia

Page 4: CLINICAL PROBLEM SOLVING WHEN YOURE ON CALL Speaker: Connie Tomada, MD.

Phone CallPhone Call

duration?

gradual or sudden?

cyanosis?

reason for admission?

presence of COPD or heavy smoking? (CO2 retainers)

oxygen order?

duration?

gradual or sudden?

cyanosis?

reason for admission?

presence of COPD or heavy smoking? (CO2 retainers)

oxygen order?

Page 5: CLINICAL PROBLEM SOLVING WHEN YOURE ON CALL Speaker: Connie Tomada, MD.

Phone CallPhone Call

Oxygen

1 L/min O2 on NC adds 3% FiO2 on RA

for CO2 retainers, start with 3-4 L/min, FiO2 29-32%

for asthma/COPD, aerosol treatment

ABG?

Oxygen

1 L/min O2 on NC adds 3% FiO2 on RA

for CO2 retainers, start with 3-4 L/min, FiO2 29-32%

for asthma/COPD, aerosol treatment

ABG?

Page 6: CLINICAL PROBLEM SOLVING WHEN YOURE ON CALL Speaker: Connie Tomada, MD.

Travel TimeTravel Time

Cardiovascular CHF, PE

PulmonaryPneumonia, asthma,

COPD

Others anxiety, upper airway obstruction, ascites

Life-threatening hypoxia

Page 7: CLINICAL PROBLEM SOLVING WHEN YOURE ON CALL Speaker: Connie Tomada, MD.

Travel TimeTravel Time

Cardiovascular CHF, PE

PulmonaryPneumonia, asthma,

COPD

Others anxiety, upper airway obstruction, ascites

Life-threatening hypoxia

Page 8: CLINICAL PROBLEM SOLVING WHEN YOURE ON CALL Speaker: Connie Tomada, MD.

BedsideBedside

rapid visual assessment (sick or critically ill?)

ABG, O2, IV access & IV fluids, ECG

crash cart and ECG monitor

code status if considering intubation (call senior resident/ICU attending)

rapid visual assessment (sick or critically ill?)

ABG, O2, IV access & IV fluids, ECG

crash cart and ECG monitor

code status if considering intubation (call senior resident/ICU attending)

Page 9: CLINICAL PROBLEM SOLVING WHEN YOURE ON CALL Speaker: Connie Tomada, MD.

BedsideBedside

ABCs and Vital signs

airway obstruction

RR<12/min: narcotic OD, cushing sign

paradoxical breathing

fever: infection vs. PE

pulsus paradoxus: asthma, COPD, cardiac tamponade

ABCs and Vital signs

airway obstruction

RR<12/min: narcotic OD, cushing sign

paradoxical breathing

fever: infection vs. PE

pulsus paradoxus: asthma, COPD, cardiac tamponade

Page 10: CLINICAL PROBLEM SOLVING WHEN YOURE ON CALL Speaker: Connie Tomada, MD.

BedsideBedside

Hypoxia (O2sat<92% or PaO2<60 mmHg)

increase oxygen support until O2 sat >92%

careful with CO2 retainer (COPD, heavy smoker), O2sat ~90%

nasal cannula face mask venturi mask non-rebreather dual flow BiPap endotracheal intubation

repeat ABG

Hypoxia (O2sat<92% or PaO2<60 mmHg)

increase oxygen support until O2 sat >92%

careful with CO2 retainer (COPD, heavy smoker), O2sat ~90%

nasal cannula face mask venturi mask non-rebreather dual flow BiPap endotracheal intubation

repeat ABG

Page 11: CLINICAL PROBLEM SOLVING WHEN YOURE ON CALL Speaker: Connie Tomada, MD.

BedsideBedside

Hypoxia (O2sat<92% or PaO2<60 mmHg)

increase oxygen support until O2 sat >92%

careful with CO2 retainer (COPD, heavy smoker), O2sat ~90%

nasal cannula face mask venturi mask non-rebreather dual flow BiPap endotracheal intubation

repeat ABG

Hypoxia (O2sat<92% or PaO2<60 mmHg)

increase oxygen support until O2 sat >92%

careful with CO2 retainer (COPD, heavy smoker), O2sat ~90%

nasal cannula face mask venturi mask non-rebreather dual flow BiPap endotracheal intubation

repeat ABG

Page 12: CLINICAL PROBLEM SOLVING WHEN YOURE ON CALL Speaker: Connie Tomada, MD.

BedsideBedside

Hypoxia (O2sat<92% or PaO2<60 mmHg)

increase oxygen support until O2 sat >92%

careful with CO2 retainer (COPD, heavy smoker), O2sat ~90%

nasal cannula face mask venturi mask non-rebreather dual flow BiPap endotracheal intubation

repeat ABG

Hypoxia (O2sat<92% or PaO2<60 mmHg)

increase oxygen support until O2 sat >92%

careful with CO2 retainer (COPD, heavy smoker), O2sat ~90%

nasal cannula face mask venturi mask non-rebreather dual flow BiPap endotracheal intubation

repeat ABG

Page 13: CLINICAL PROBLEM SOLVING WHEN YOURE ON CALL Speaker: Connie Tomada, MD.

BedsideBedside

Hypoxia (O2sat<92% or PaO2<60 mmHg)

increase oxygen support until O2 sat >92%

careful with CO2 retainer (COPD, heavy smoker), O2sat ~90%

nasal cannula face mask venturi mask non-rebreather dual flow BiPap endotracheal intubation

repeat ABG

Hypoxia (O2sat<92% or PaO2<60 mmHg)

increase oxygen support until O2 sat >92%

careful with CO2 retainer (COPD, heavy smoker), O2sat ~90%

nasal cannula face mask venturi mask non-rebreather dual flow BiPap endotracheal intubation

repeat ABG

Page 14: CLINICAL PROBLEM SOLVING WHEN YOURE ON CALL Speaker: Connie Tomada, MD.

BedsideBedside

Hypoxia (O2sat<92% or PaO2<60 mmHg)

increase oxygen support until O2 sat >92%

careful with CO2 retainer (COPD, heavy smoker), O2sat ~90%

nasal cannula face mask venturi mask non-rebreather dual flow BiPap endotracheal intubation

repeat ABG

Hypoxia (O2sat<92% or PaO2<60 mmHg)

increase oxygen support until O2 sat >92%

careful with CO2 retainer (COPD, heavy smoker), O2sat ~90%

nasal cannula face mask venturi mask non-rebreather dual flow BiPap endotracheal intubation

repeat ABG

Page 15: CLINICAL PROBLEM SOLVING WHEN YOURE ON CALL Speaker: Connie Tomada, MD.

BedsideBedside

Hypoxia (O2sat<92% or PaO2<60 mmHg)

increase oxygen support until O2 sat >92%

careful with CO2 retainer (COPD, heavy smoker), O2sat ~90%

nasal cannula face mask venturi mask non-rebreather dual flow BiPap endotracheal intubation

repeat ABG

Hypoxia (O2sat<92% or PaO2<60 mmHg)

increase oxygen support until O2 sat >92%

careful with CO2 retainer (COPD, heavy smoker), O2sat ~90%

nasal cannula face mask venturi mask non-rebreather dual flow BiPap endotracheal intubation

repeat ABG

Page 16: CLINICAL PROBLEM SOLVING WHEN YOURE ON CALL Speaker: Connie Tomada, MD.

BedsideBedside

Hypoxia (O2sat<92% or PaO2<60 mmHg)

increase oxygen support until O2 sat >92%

careful with CO2 retainer (COPD, heavy smoker), O2sat ~90%

nasal cannula face mask venturi mask non-rebreather dual flow BiPap endotracheal intubation

repeat ABG

Hypoxia (O2sat<92% or PaO2<60 mmHg)

increase oxygen support until O2 sat >92%

careful with CO2 retainer (COPD, heavy smoker), O2sat ~90%

nasal cannula face mask venturi mask non-rebreather dual flow BiPap endotracheal intubation

repeat ABG

Page 17: CLINICAL PROBLEM SOLVING WHEN YOURE ON CALL Speaker: Connie Tomada, MD.

BedsideBedside

Hypoxia (O2sat<92% or PaO2<60 mmHg)

increase oxygen support until O2 sat >92%

careful with CO2 retainer (COPD, heavy smoker), O2sat ~90%

nasal cannula face mask venturi mask non-rebreather dual flow BiPap endotracheal intubation

repeat ABG

Hypoxia (O2sat<92% or PaO2<60 mmHg)

increase oxygen support until O2 sat >92%

careful with CO2 retainer (COPD, heavy smoker), O2sat ~90%

nasal cannula face mask venturi mask non-rebreather dual flow BiPap endotracheal intubation

repeat ABG

Page 18: CLINICAL PROBLEM SOLVING WHEN YOURE ON CALL Speaker: Connie Tomada, MD.

BedsideBedside

Hypoxia (O2sat<92% or PaO2<60 mmHg)

increase oxygen support until O2 sat >92%

careful with CO2 retainer (COPD, heavy smoker), O2sat ~90%

nasal cannula face mask venturi mask non-rebreather dual flow BiPap endotracheal intubation

repeat ABG

Hypoxia (O2sat<92% or PaO2<60 mmHg)

increase oxygen support until O2 sat >92%

careful with CO2 retainer (COPD, heavy smoker), O2sat ~90%

nasal cannula face mask venturi mask non-rebreather dual flow BiPap endotracheal intubation

repeat ABG

Page 19: CLINICAL PROBLEM SOLVING WHEN YOURE ON CALL Speaker: Connie Tomada, MD.

Intubation???Intubation???12<RR>30/min

inability to protect airway

change in MS

paradoxical breathing

pH<7.35

normal pH with tachypnea

PaO2<60

PCO2>50

Full Code

when you think it’s needed

12<RR>30/min

inability to protect airway

change in MS

paradoxical breathing

pH<7.35

normal pH with tachypnea

PaO2<60

PCO2>50

Full Code

when you think it’s needed

Page 20: CLINICAL PROBLEM SOLVING WHEN YOURE ON CALL Speaker: Connie Tomada, MD.

Causes of Shortness of Breath

Causes of Shortness of Breath

A quick reviewA quick review

Page 21: CLINICAL PROBLEM SOLVING WHEN YOURE ON CALL Speaker: Connie Tomada, MD.

Acute CHFAcute CHF

Hx of CHF or cardiac disorder, orthopnea/PND, + I/O, weight gain

signs of fluid overload (JVD, insp crackles +/- pleural effusion, systolic murmurs, + HJR, edema)

chest xray

decrease preload: sit patient up, oxygen, furosemide, NTG, morphine

look for cause of CHF

Hx of CHF or cardiac disorder, orthopnea/PND, + I/O, weight gain

signs of fluid overload (JVD, insp crackles +/- pleural effusion, systolic murmurs, + HJR, edema)

chest xray

decrease preload: sit patient up, oxygen, furosemide, NTG, morphine

look for cause of CHF

Page 22: CLINICAL PROBLEM SOLVING WHEN YOURE ON CALL Speaker: Connie Tomada, MD.

Causes of CHFCauses of CHFCAD

HTN

valvular heart disease

cardiomyopathies

pericardial disease

MI

Fever, infection

dysrhythmia

PE

NSAIDS

anemia

CAD

HTN

valvular heart disease

cardiomyopathies

pericardial disease

MI

Fever, infection

dysrhythmia

PE

NSAIDS

anemia

Page 23: CLINICAL PROBLEM SOLVING WHEN YOURE ON CALL Speaker: Connie Tomada, MD.

Pulmonary EmbolismPulmonary EmbolismTachypnea, tachycardia and chest pain, Virchow’s triad (e.g. hypercoagulable state, immobility, vein injury), History of DVT

Pleural rub, pleural effusion, lower extremity with edema/palpable cord/calve tenderness

Stat ECG (S1Q3T3), stat CXR, stat CTA chest, echo, LE Doppler, d-dimer

Heparin vs LMWH, IVC filter, thrombolysis if in shock (call senior resident)

ICU transfer if with low oxygen saturation +/- intubation

Tachypnea, tachycardia and chest pain, Virchow’s triad (e.g. hypercoagulable state, immobility, vein injury), History of DVT

Pleural rub, pleural effusion, lower extremity with edema/palpable cord/calve tenderness

Stat ECG (S1Q3T3), stat CXR, stat CTA chest, echo, LE Doppler, d-dimer

Heparin vs LMWH, IVC filter, thrombolysis if in shock (call senior resident)

ICU transfer if with low oxygen saturation +/- intubation

Page 24: CLINICAL PROBLEM SOLVING WHEN YOURE ON CALL Speaker: Connie Tomada, MD.

PneumoniaPneumonia

cough productive of purulent sputum, fever/chills, pleurisy, +/- immunocompromised

leukocytosis, bandemia, CXR

sputum GS/CS, Strep/Mycoplasma/Legionella Ag, blood culture

antibiotics (refer to guidelines)

cough productive of purulent sputum, fever/chills, pleurisy, +/- immunocompromised

leukocytosis, bandemia, CXR

sputum GS/CS, Strep/Mycoplasma/Legionella Ag, blood culture

antibiotics (refer to guidelines)

Page 25: CLINICAL PROBLEM SOLVING WHEN YOURE ON CALL Speaker: Connie Tomada, MD.

Bronchospasm (Asthma/COPD)Bronchospasm (Asthma/COPD)

tobacco abuse, steroid use, intubation history, precipitating factors, anaphylaxis

diffuse wheezing, prolonged expiration, loud P2

somnolence, pulsus paradoxus, cyanosis, accessory muscle

CXR, ABG, spiromtery, pulse ox

oxygen, aerosols, steroid, antibiotics

tobacco abuse, steroid use, intubation history, precipitating factors, anaphylaxis

diffuse wheezing, prolonged expiration, loud P2

somnolence, pulsus paradoxus, cyanosis, accessory muscle

CXR, ABG, spiromtery, pulse ox

oxygen, aerosols, steroid, antibiotics

Page 26: CLINICAL PROBLEM SOLVING WHEN YOURE ON CALL Speaker: Connie Tomada, MD.

Always remember...Always remember...

Call your senior resident if you need some assistance.

Perform proper hand-offs and sign-out

Call your senior resident if you need some assistance.

Perform proper hand-offs and sign-out

Page 27: CLINICAL PROBLEM SOLVING WHEN YOURE ON CALL Speaker: Connie Tomada, MD.

CLINICAL PROBLEM SOLVING WHEN YOU’RE

ON CALL

CLINICAL PROBLEM SOLVING WHEN YOU’RE

ON CALL

• How to work-up and manage

• Shortness of Breath

• How to work-up and manage

• Shortness of Breath