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Saturday, September 1, 2007

Case Presentation (Resp Distress C O P Datypical)

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Resp Distress C O P Datypical Slideshow Transcript

Slide 1: Case Presentation Aaron Sibley PGY 3 Emergency Medicine

Slide 2: Objectives: • Learn two “take-home” messages. • Help us all look as smart as Rob2 . • Have fun with an interesting case.

Slide 3: “Take-home” Messages: • “Not all that wheezes is asthma” holds for young to middle aged adults too. • COPD can occur in young to middle aged adults. • Bonus: Recognize potential cognitive errors early and avoid.

Slide 4: Case: • The setting: RAH (newer and better smelling ‘B’ side), Friday night, working with “The Sos”. • From the desk: a forty something, tall, thin Black male, tripod in bed, diaphoretic, rapid laboured breathing-nurse at side. • R1: a) Sick or not sick? b) Initial actions? • Answers: a) Sick. b) ABCs/IV O2 monitor.

Slide 5: Case con’t 2: • As you arrive at the bedside, the nurse says that the patient has a history of asthma, that he drove himself to the ED, and that his sats were 70% at triage. • You ask the patient “Do you have asthma, does this feel like your asthma, what brought it on?”. • The patient states that he has had asthma for 20 years, this is the worst time, and that he got a cold from his 2 daughters 3 days ago and has been getting wheezier and more SOB since.

Slide 6: Case con’t 3: • A: talking in rapid sentences, no stridor. • B: RR 23, sats 98% 10L nonrebreather, breath sounds- increased exp phase (R1 what is normal ratio of insp to exp?) and wheezes throughout, + accessory muscle use, trachea midline, no sub cut emphysema. • C: P 70, BP 138/93, PPP. • D: GCS 15, pupils PERL x2. • E: Temp 36.4 Celsius.

Slide 7: Case con’t 4: • The nurse is at the bedside waiting for direction, R2: Do you take a more compete Hx first then decide on tx/investigations, or do you make decisions now with little info? • Answer: Get things started early with sick patients, don’t worry about over investigating, tx takes time to initiate and you can cancel when more info available.

Slide 8: Treatment/Investigations: • R3: What tx, what tests/investigations? • Answer: Tx: 3 back-to-back masks (Ventolin 5mg/Atrovent 500ug), IV steroids (125mg Methylprednisilone), MgSO4 (2g over 20 mins) Inv/tests: CBC,Lytes, BUN/Cr, CXR (portable), EKG, ABG, peak flow.

Slide 9: History: • Pt describes 20 year hx of asthma, dx’d by family doc. • Last 3 months getting worse, very SOB walking up 1 flight stairs, emptying ventolin puffer q 1wk. • Caught URI from daughters 3 days ago, since getting +++ SOB, 50 puffs ventolin/day- put off coming in until couldn’t breathe.

Slide 10: History: • Questions? • No fever, + dry cough, very wheezy last 3 days. • No CP/HTN/heart troubles, mild HA, no PE risk factors. • Meds: ventolin prn, Allergies: none (no environmental). • PMed Hx: Cocaine use 10 years ago, 35 pk year hx, no ICU/intubations, no ED visits. • Vocation: DJ, singer. • Fam Hx: father died from emphysema in 40s.

Slide 11: Results: labs/investigations: • Please describe this CXR, what potential complication if Asthma are we worried about? • Answer: Large volumes, flat diaphragms, no focal pathology. Pneumothorax. • Please explain this ABG? The patient did not respond well to initial tx, what treatment might this prompt you to start/think about? • Answer: ?Acute on chronic resp acidosis. Bipap (pt tolerated full face well and started to feel better in mins).

Slide 12: CXR: Back

Slide 13: ABG: • 7.22/79/88/30.9 • Acidosis, respiratory (acute roughly 10/1 compensation. Chronic 10/3.5) • Expected comp is increase in bicarb 3.9 if acute 10.5 if chronic Back

Slide 14: Summary of Pt: • 44 year old male, 20 yr hx of asthma,35 pk year smoker, increased SOB in exertion last month, 3 day hx URTI and severe SOB, on exam hypoxic but normal LOC, CXR shows hyperinflation, Blood gas resp acidosis (acute on chronic), minimal response to bronchodilators/Mg/steroids, significant improvement with Bipap. • R4: Is this asthma? Why or why not?

Slide 15: Why not Asthma?: • 1) Hypoxia • 2) CO2 level • 3) Heavy smoker

Slide 16: Asthma Differential Diagnosis: • R2: What is the Dif Dx of Acute Asthma exacerbation? • COPD • Anaphylaxis • Foreign Body Aspiration • IV Drug induced (Talc lung), non IV (ACE) • Cardiac Asthma • Vocal cord paralysis • Pulmonary embolis

Slide 17: What Cognitive Errors? • Anyone: Name 3 cognitive errors that were made in this case? • 1) Diagnosis momentum • 2) Symptom cueing • 3) Anchoring

Slide 18: Course in Hospital: • ICU consulted in case pt progressed to Intubation {art line placed for repeat gases q 2h while on Bipap (full face)} • ICU suggests COPD…..what test did ICU ask to be ordered? • Based on mild improvements in gases (pH and CO2), Pulmonary also consulted. Pt started on Levofloxacin, remained on Bipap 3 days on Pulm ward. • PFTs showed severe obstructive lung disease. CT Chest mod. centrilobular emphysema. • Pt D/C’d home in stable condition (ABG 7.43/55/57/30.9), educated about smoking cessation, started on combivent, po steroids.

Slide 19: Pulmonary Function Tests: FEV1 1.51L (36% pred) FVC 3.4L (65% pred) FEV1/FVC (44%) 1. FEV1>=70% predicted : Mild 2. FEV1=50-69% predicted : Moderate 3. FEV1<50% predicted : Severe Back

Slide 20: Questions?

Slide 21: “Take-home” messages: • “Not all that wheezes is asthma” holds for young to middle aged adults too. • COPD can occur in young to middle aged adults. • Bonus: Recognize potential cognitive errors early and avoid.

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