HPI:
52 year old man presenting via CFD wtih acute onset of shortness of breath. Per CFD patient was sitting on the edge of his couch holding his inhaler with moderate respiratory distress. En route he was given 2 treatments of nebulized bronchodilators without much improvement in symptoms. The patient is refusing to lay on cart sitting on edge of cart, anxious appearing with only one word answers to questions.
From a brief review of electronic medical record you see:
Past Medical History: HTN, asthma (moderate persistent)
Medications: Combivent MDI, Singulair, Lisinopril, HCTZ
Allergies: NKDA
Social History: 20 pack year smoking history - continues to smoke 1/2 pack per day
Vital Signs:
T 99.2F HR 100 BP 154/92 RR 40 SaO2 88% on 2L via NC
Gen: middle aged man in moderate respiratory distress
HEENT: clear op otherwise unremarkable
Neck: habitus limits jvd assessment, no visible jvd
Pulm: exp wheezing diffusely, no rales, intercostal retractions and tracheal tug noted
CV: tachycardic, reg rhythm, no murmurs, normal s1/s2, no rubs
Abd: soft, nd, nt, +bs
Extrem: 2+ distal pulses throughout
Neuro: alert, oriented, no focal motor/sensory deficits
Skin: warm, no rashes noted
ED Course:
As you ordered patient started on continuous neb, given IV methylpred, mag sulfate while IV, O2 via NRB started and placed on monitor. Respiratory is en route with noninvasive ventilation and your tech is setting up intubation equipment and RSI medications in case necessary...
Labs are not yet back however you have access to the following EKG and CXR...
Despite continuous neb, iv corticosteroids and mg sulfate patient continues to have moderate respiratory distress... repeat vitals are obtained:
T 99.5F HR 130 BP 102/64 RR 44 SaO2 90% on NRB
- What is the diagnosis? What treatment needs to be initiated for this?
General questions pertaining to asthma management in the ED...
- What criteria can be used to determine suitability for admission to the hospital for patients with asthma exacerbations?
- What criteria can be used to determine readiness for discharge from the ED or hospital?
---------------------- (scroll down for answers)-------------------------
Diagnosis: Tension Pneumothorax
Treatment: Needle decompression and chest tube placement
What criteria can be used to determine suitability for admission to the hospital for patients with asthma exacerbations?
After treatment in the emergency department for 1 to 3 hours, patients who have an incomplete or poor response, defined as an FEV1 or PEF of less than 70% of the personal best or predicted value, should be evaluated for admission to the hospital. Patients who have an FEV1 of less than 40%, continuing moderate-to-severe symptoms, drowsiness, confusion, or a partial pressure of arterial carbon dioxide of 42 mm Hg or greater should be admitted.
What criteria can be used to determine readiness for discharge from the ED or hospital?
According to the authors, patients may be discharged if the FEV1 or PEF after treatment is 70% or more of the personal best or predicted value and the lung function and improvement of symptoms are sustained for at least 60 minutes. After discharge, patients should continue to use inhaled short-acting β2-adrenergic agonists as needed and should be prescribed oral corticosteroids for 3 to 10 days. Reference:
Lazarus, S. Emergency Treatment of Asthma. N Engl J Med 2010; 363:755-764
My initial management priorities are the ABCs. The patient can only speak one word at a time and is leaning forward in bed probably using accessory muscles to breathe. He is unresponsive to 2 nebulizer treatments so might have to go up on the oxygen or try a nonrebrether mask. We should get 2 large bore IVs going, continuous pulse oximetry, ABGs, BP reading and watch for signs of respiratory fatigue that might require the patient to be intubated (increased CO2, decreasing O2 sats). Give a trial of ipotropium, proventil nebs PRN and 40 of prednisone and assess clinical response. Repeat ABG in 1-2 hours and continuously reassess response to therapy. We would want a CXR as well to investigate the trigger for the exacerbation, blood work (CBC, BMP, CK, troponin), ECG. Admit patient if non-responsive or if still in respiratory distress (although may be somewhat improved) for monitoring of respiratory status. My initial DDx would be Acute asthma exacerbation, COPD exacerbation (smoking history in an older man), and in the back of my head a PE due to the acute onset of the SOB. ACS may be a consideration due to the risk factor of HTN.
ReplyDeleteMy intial management of this patient would be the ABCs. The patient is currently using accesory muscles to breath as well as unable to speak in complete sentences. It is crucial to ensure that he can maintain his airway. In addition, I would start 2 16G IVs to ensure that we had access in case there was a need for intubation. In addition, I would place the patient on a pulse ox monitor, get another BP, and monitor his HR (considering the multiple albuterol treatments he is receiving). I would increase the oxygen from 2L to 4L to see if there was improvement. If not and his oxygen saturation remained less than 92%, I would try a non rebreather as well an additional nebulizer treatment with albuterol/ipratropium. I would reassess the patient clinically to determine next course of action - if still having difficulty maintaining airway with decreased respiratory rate, mental status change, would consider RSI at this time. Meanwhile, would order CBC, BMP, ABG, CXR, ECG, Trop. Would give prednisone 60mg and would consider Mg 2g IV if continuing exacerbation. At this point: DDX of asthma exacerbation vs COPD exacerbation vs PE vs ACS. Would continue to reassess patient's response to therapy. Would consider admiting patient, depending on respiratory status and response to treatment in ED. Would also speak with family to explain to them his condition and to learn more about his baseline at home.
ReplyDelete1. Cardiac monitor, pulse Ox, IVs x2. Get CPAP machine. 100 IV methylprednisolone x1.
ReplyDeletewait 5 minutes to see if he improves and get chest xray STAT and EKG stat. VBG or ABG stat.
Ask patient if okay with possible intubation.
Would prepare intubation equipment 3/4 blade/handle/ 7.5 and 8mm tube. 4mg versed + 20mg Etomidate +100mg succ RSI (since maybe be full stomach). Have staff get suction and ambu bag with oxygen attached. Have staff page respiratory therapy for vent machine.
I would only wait on chest xray rule out pneumo and ABG to see PH and Co2 level to see if he has acidemia otherwise after two failed neb treatments I would intubate. vent settings 500cc tidal volume 16 frequency at 100% oxygen.
Chest xray to investigate Pneumothroax vs Pnx vs Tamponade/effusion (would give 40 lasix if fluid overload)
EKG/TN to investigate ACS.
cbc - hb. bmp for electrolytes and glucose
Depending on Results of above PE (CT chest)
DDx: Asthma exacerbation/ACS/PE/Pneumo/Pnx/Effusion/tamponade
By Farhan Mazhar
First priority with initial management of this patient is protecting his airway. In light of him already receiving multiple treatments enroute to the ED with no improvement, I would be worried that he may decompensate quickly secondary to this rapid respiratory rate and would make sure to have CPAP/BIPAP, intubation kit ready at bedside prior to his arrival. (AKA, pt needs should be brought into resuscitation area).
ReplyDeleteOn Arrival:
Primary survey: Ask the patient his name, if he can talk, airway if patent, if not, immediate intubation with preoxygenation first. Then make sure the patient does not have any signs of trauma to the chest, abdomen or trunk. If he has been stabbed in the chest, or appears to have been in a major accident, may be having a tension pneumo/pnuemothorax/cardiac tamponade from aortic rupture/lung contusion that is causing his respiratory distress. Quickly listen to patients lungs and assess for presence of bilateral and equal breath sounds. If they are not present and especially if patient shows signs of tracheal deviation, NEEDLE thoracotomy in 2nd intercostal space STAT... then eventually chest tube. If there are signs of trauma, and breath sounds are bilateral, assess pts GCS quickly, and if <8, intubate!!! Patient will need stat: 2 large bore peripheral IVs and room temp fluids running, hooked up to monitor, fast exam to rule out cardiac tamponade/intrabdominal bleeding, chest and pelvis xray, possible c spine immobilization. Then labs: cbc, bmp, coags incase pt needs to go to the OR, possible urine and drug tox if suspicion is high. Pt may also need CT head if there is trauma.
If there are no signs of trauma, and this appears more likely to be severe asthma exacerbation/COPD exacerbation, I would have a low threshold to place the patient on BIPAP/CPAP as quickly as possible to keep him from tiring out since I don’t know how long he has been short of breath for, and a resp rate of 40 is hard to maintain. It is much better to try to NOT intubate these people if CPAP/BIPAP can fix the problem. Continuous nebs are also an option, but if patient was not responsive to multiple treatments in route, I would use it w/ CPAP/BIPAP. Then obtain IV access, and hook the patient up to the monitor to assess his vitals/respiratory status. Stat chest x ray and ECG to check for MI, pneumonia, CHF, flash pulmonary edema, infectious causes (aka, PCP-like pattern, fungus ball, TB). I would also give pt some IV magnesium(2g) and solumedrol (10mg) to reduce pulmonary bronchospasm.
If patient is not improving with CPAP/BIPAP, I would intubate him using RSI with etomidate and succ, and hook him up to the ventilator. Then labs and MICU consult to beside STAT.
Labs: CBC, CMP to check for his electrolyte/metabolic status that could cause him to become tachypnic (ie: acidemia), troponin to rule out cardiac ischemia as a cause, VBG to assess CO2 status/pH, and coags incase it is an MI and he needs STAT PCI. If suspicion is high, urine and drug tox might be able to help as well.
What would be in the back of my mind that was not mentioned above: Anaphylaxis… would try IM epi to see if it helps if suspicion is high. PE, but would need a little more history to go down these paths. I would try to see if EMS or family could give me any additional information after ensure patient has a definitive airway/is stable from a respiratory standpoint, and Vitals are stable (aka, pt is not hypotensive). Always remember, ABCs first!!!
Everyone has relayed important thoughts re: the case. Not to echo what everyone has reiterated, but I agree that it's crucial to be mindful of a pt's ABCs, especially when this particular pt is hemodynamically compromised. Initial assessment with whatever history I can get, vitals, and a quick physical exam is where I'd begin. My DDx in someone like him would include asthma/copd exac. v. PNX v. PE v. ACS v. CHF exacerbation v. PNA, tamponade, etc.. Next, ABG and PIV access, EKG, placing the pt on a cardiac monitor, CXR, and basic labs - CBC, CMP, coags, trop, BNP. If the pt is hypercarbic, hypoxemic, or significantly acidemic, I would proceed with CPAP/BIPAP first before thinking about intubation. However, if he begins to develop altered mental status or increased somnolence/sluggishness, I wouldn't wait for the ABG before trying noninvasive or invasive ventilation. Another med neb with atrovent/albuterol and IV solumedrol 125 mg may be helpful as well. If he continues to seem anxious, an anxiolytic may be beneficial. After the aforementioned steps have been taken, I'd re-assess the pt and go from there.
ReplyDeleteStart with ABC's. He hasn't improved on 2 neb treatments of bronchodilators, so I'd give him a combined neb immediately, first with nonrebreather, but with low threshold for starting CPAP/BiPAP. I'd also start 2 large bore IV's, and give 40 prednisone IV, and make sure he has pulse ox monitor on. I'd also start getting intubation equipment ready just in case. Since he didn't respond to earlier treatments, I'd want to try ruling out other causes of respiratory distress, like PTX, tension pneumo, PE, tamponade, MI, CHF exacerbation with short history and physical exam. I'd listen to his lungs and see if breath sounds are present on both sides, look for tracheal deviation, listen for pulmonary edema. I'd get a stat CXR and ECG. As far as labs, I'd want CBC, CMP, ABGs, Tn, CK-MB, BNP, coags in case he rules in for ACS.
ReplyDeleteExcellent work thus far! A couple of thoughts to follow up on your comments...
ReplyDelete• Everyone correctly answered ABC’s… when you are taking care of ‘sick’ patients in the ED always have the EM mantra in the back of your mind… “ABCs, IV, O2, monitor”
• Good job keeping your differential broad despite this looking like asthma/COPD exacerbation… in a 52 yo hypertensive smoker ACS, CHF, PE may also cause respiratory distress, wheezing
• A few of you also mentioned magnesium sulfate - another great bronchodilating agent with good evidence to support its use in moderate to severe asthma exacerbations
• Many of you correctly identified the possible need for rapid sequence intubation in this patient… if headed this route consider non-invasive ventilation (BiPAP) as an early way to either avoid or transition to RSI… also in terms of RSI agents strongly consider using ketamine as induction agent in asthmatics as it acts as a bronchodilator
Keep up the great work! Don’t feel as though you need to make your post too long - can keep it short and sweet if you have a quick thought to add…
Dr. Casey... this X ray is BAD news... This is a tension pneumothorax! Definite tracheal deviation to the L, the entire contents of the mediastinum are L of midline, there are decreased pulmonary markings on the R, and you can see the lining of the R lung pulled away from the chest cavity. This patient needs an emergent needle thoracotmy in midclavicular L 2nd intercostal space and chest tube to relieve his respiratory distress! MICU admission!
ReplyDeleteTo admit a patient to the hospital for asthma, the patient must not be improving with treatment, have severe symptoms, epescially if they required intubation or have a history of respiratory failure in the past, or require BIPAP/CPAP. If the patient continues to require O2 and desaturates with walking, i would definetely admit them, at least for observation.
To discharge a patient, the pt must improve significantly, saturate above 94% on room air, no desaturations with walking, peak flow back to their baseline with few treatments.
This is a tension pneumothroax as evidenced by the mediastinal shift and collapsed lung. Patient needs a chest tube in the 2nd ICS midclavicular line and admission to MICU.
ReplyDeleteTo discharge an asthma patient they patient has to saturate well (>94%) on RA and significantly improve after treatment. Patient has to tolerate room air and be able to ambulated without desaturating to prove relief of airway obstruction. The patient can still have some wheezing on exam but cannot be in significant respiratory distress.
If the patient is unresponsive to treatment and requires bipap or intubation then admission is warranted. If the patient continues to desaturate then he/she would need to be admitted for observation.
This is a tension pneumothorax big time and per the CXR this is an impressive lesion. Thus he needs a chest tube and MICU admission.
ReplyDeleteIn regards to asthma I like to ask certain question in my history b/c they tend to guide treatment. I specifically like to ask, "how much symptoms do you experience a week, any nighttime symptoms, how often do you use your albuterol inhaler a week."