CLINICAL PROBLEM
SOLVING WHEN YOU’RE
ON CALL
Speaker: Connie Tomada, MD
CLINICAL PROBLEM
SOLVING WHEN YOU’RE
ON CALL
How to work-up and manage
Shortness of Breath
Shortness of Breath
Cardiovascular
CHF, PE
Pulmonary
Pneumonia, asthma, COPD
Others
anxiety, upper airway
obstruction, ascites
Life-threatening
hypoxia
Phone Call
duration?
gradual or sudden?
cyanosis?
reason for admission?
presence of COPD or heavy smoking? (CO2
retainers)
oxygen order?
Phone 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?
Travel Time
Cardiovascular
CHF, PE
Pulmonary
Pneumonia, asthma, COPD
Others
anxiety, upper airway
obstruction, ascites
Life-threatening
hypoxia
Travel Time
Cardiovascular
CHF, PE
Pulmonary
Pneumonia, asthma, COPD
Others
anxiety, upper airway
obstruction, ascites
Life-threatening
hypoxia
Bedside
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)
Bedside
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
Bedside
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 nonrebreather dual flow BiPap endotracheal
intubation
repeat ABG
Bedside
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 nonrebreather dual flow BiPap endotracheal
intubation
repeat ABG
Bedside
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 nonrebreather dual flow BiPap endotracheal
intubation
repeat ABG
Bedside
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 nonrebreather dual flow BiPap endotracheal
intubation
repeat ABG
Bedside
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 nonrebreather dual flow BiPap endotracheal
intubation
repeat ABG
Bedside
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 nonrebreather dual flow BiPap endotracheal
intubation
repeat ABG
Bedside
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 nonrebreather dual flow BiPap endotracheal
intubation
repeat ABG
Bedside
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 nonrebreather dual flow BiPap endotracheal
intubation
repeat ABG
Bedside
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 nonrebreather dual flow BiPap endotracheal
intubation
repeat ABG
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
Causes of Shortness of
Breath
A quick review
Acute 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
Causes of CHF
CAD
HTN
valvular heart disease
cardiomyopathies
pericardial disease
MI
Fever, infection
dysrhythmia
PE
NSAIDS
anemia
Pulmonary Embolism
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
Pneumonia
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)
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
Always remember...
Call your senior resident if you need some
assistance.
Perform proper hand-offs and sign-out
CLINICAL PROBLEM
SOLVING WHEN YOU’RE
ON CALL
•
How to work-up and manage
•
Shortness of Breath