Category: Thoracic and Respiratory

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5 core treatments and 5 MORE treatments

5 Core Treatments

• Albuterol
  • Beta agonist
    • Bronchodilator
  • Core treatment for asthma
• Ipratropium
  • Anti-muscarinic
    • Relax muscles around the airways
  • Works synergistically with albuterol
• Steroids
  • Decrease inflammation in the airways
  • Prednisone (PO)
  • Methylprednisone (IV)
• BiPAP (COPD)
  • Decreases work of breathing
  • Decreases rates of intubation
  • Decreases mortality
• Antibiotics (COPD)
  • Infection common cause of inflammation

5 More Treatments

• Magnesium sulfate
• Ketamine
• Epinephrine (systemic beta agonist)
• Heliox
• LAST RESORT – Intubation
  • Decrease rate and volume
  • Increase expiratory time and inspiratory flow

Additional Reading

• Antibiotics in COPD (AAFP)
• The Crashing Asthmatic (REBEL EM)

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Introduction

Pulmonary embolism (PE) is caused when a deep venous thrombosis from somewhere else in the body “embolizes” and becomes lodged in the pulmonary arteries

Can cause pulmonary infarction (which mimics pneumonia on chest x-ray)

Basic Approach to the Diagnosis of PE

• Step 1: Consider PE in any patient with signs or symptoms consistent with the disease
  • Common signs/symptoms
    • Shortness of breath
    • Chest pain
    • Syncope
    • Tachycardia
    • Hypoxemia
    • Hypotension
• Step 2: Do not do additional testing for PE in patients with a CLEAR alternative diagnosis
  • Common alternative diagnoses
    • COPD exacerbation
    • Acute coronary syndrome
    • Pneumonia
  • Keep in mind that these diagnoses are also the most frequent misdiagnoses in cases of missed PE!!! Be careful.
• Step 3: Calculate Wells Score and PERC criteria
  • Wells score
    • (I personally use Wells’ Criteria for PE by MDCalc)
    • Define patient as either “Low” “Medium” or “High” risk
  • PERC criteria
    • I use the PERC Rule for PE by MDCalc for this as well
  • If patient is both low risk wells and meets all PERC criteria…
    • No additional testing needed!!!
• Step 4: Get a D-Dimer
  • IF…
  • Low risk Wells but fails PERC criteria
  • Medium risk Wells score
• Step 5: Get a CTA
  • IF…
  • Wells score is high
  • Elevated d-dimer
    • (Update: it is now established that you can safely use AGE ADJUSTED D-DIMER)
      • ACEP’s clinical policy supporting this can be found HERE

Final Thoughts

• Bilateral lower extremity ultrasounds not sensitive enough to rule out PE
• The classic EKG finding is S1Q3T3

Additional Reading

• Emergency Evaluation of PE: Diagnosis (Journal of Emergency Medicine)
• Wells Criteria (MDCalc)
• PERC Criteria (MDCalc)
• Age Adjusted D-Dimer Policy (ACEP)

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There are 3 main “categories” of hemoptysis…

Mild, “Streaky” Hemoptysis

• Most common diagnosis
  • Bronchitis
• Testing plan
  • Chest xray
    • Rules out alternative causes of hemoptysis
      • Pneumonia
      • Cancer
      • Pulmonary Embolism
      • Vasculitis

Scary but Stable Hemoptysis

• Patient is coughing up frank blood
• Testing plan
  • CTA of the chest
  • CBC
  • PTT/PT/INR
  • Electrolytes
    • Need renal function if giving IV contrast

Oh-My-God-That’s-A-Lot-Of-Blood!!!

• Intubate the patient
• Consult cardiothoracic surgery/interventional radiology

Additional Reading

• Hemoptysis: An EM Primer (emDOCs)

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You need an organized, anatomical approach.

Step 1: Consider Differential Diagnosis

• Upper airway
  • Angioedema
  • Foreign body
  • Abscess
• Lower airway
  • COPD
  • Asthma
• Alveoli
  • Pneumonia
  • Pulmonary edema
• Blood
  • Anemia
  • Acidosis
    • DKA
    • Sepsis (lactic acid)
    • Toxins (salicylic acid)
• Blood vessels
  • Pulmonary embolism
  • Aortic dissection
• Heart
  • Myocardial infarction
  • Acute heart failure
  • Cardiac tamponade

Step 2: Examine Anatomically

• Upper airway
  • Stridor
  • Voice changes
• Lower airway
  • Wheezing
• Alveoli
  • Crackles
• Blood
  • Pallor
• Heart
  • Dysrhythmia
  • Jugular vein distension (JVD)
  • Edema

Step 3: Testing Plan

• Common tests
  • Chest x-ray
  • EKG
  • CBC
  • Electrolytes
• Less common tests
  • Blood gas
  • Troponin
  • BNP
  • D-Dimer

Step 4: Calculate Wells Score and PERC

• Wells Score (MDCalc)
• PERC Rule (MDCalc)

Additional Reading

• Pulmonary Embolism (EM Clerkship)
• Shortness of Breath (SAEM)