COPD vs CHF vs MI vs PE ????????

[crotchitymedic1986]

Since you said anything could be asked..

Ever had wheezes/sob before? NO

Does (and how much) activity make him SOB and/or dizzy? STARTED SOB, ANY ACTIVITY WORSENS IT

Headache? Anxious? HA - NO, ANXIOUS - SLIGHTLY

Family history? FATHER HAS HYPERTENSION, HAD STENTS PLACED AT AGE 75, MOM HAD ALZHEIMERS

What does the patient do for work? HE IS AN ACCOUNTANT

I'm leaning toward COPD (although that BP and possibility of masked rales bothers me), but want to know a bit more history. Good LOC/skins with sats of 88% suggest chronically low PaO2.

Initial Tx:

O2, IV TKO,

Albuterol (wary of BP and want to know more history)

Standing by with nitro and getting answers to questions..

Reassess lungs throughout treatment looking for anything besides wheezes.

I would kinda go from there after reassessment..

ANSWERS WITHIN BOX

[CTXMEDIC]

Im not thinking so much that this is a CHF pt, #1 no history of CHF, no crackles or rhonchi. correct?

Possibly a PE. however like it was said before he's not having any CP, is he experiencing any calf tenderness?

I would treat him like any other respiratory pt, presenting with SOB and wheezing. O2, Monitor, IV, Neb treatment. possibly NTG for the pressure. but would give the neb first and re-assess after that as far as breathing and maybe the use of NTG.

The wheezing from CHF is why its also referred to as 'cardiac asthma'. i was considering a neb tx as well but this doesnt appear to be from bronchoconstriction. I think NTG is indicated as well but not for the pressure. more than likley this guys got chronic HTN with a Hx like that. remember that just because theres no 'official' history of a disease doesnt mean it doesnt exist. this patient hasnt been to a doc in years per the scenario. who knows, maybe we're all shootin blanks.....i dont think either of our proposed tx will make him any worse which is a good thing

[crotchitymedic1986]

You are right in that your treatment will not hurt the patient, but if it is CHF or MI, an aerosol treatment will not do alot of good. If it is COPD, then an aerosol treatment migh help alot. This patient could have any of the diagnosis' listed above. Anybody else got a suggestion for how you would differentiate ?

[ksemt]

Ok guys, I'll gratiously accept positive criticism as I'm a relatively new medic in a rural area and I don't see a lot but try to refrain from ripping me up too bad.

My thoughts on this pt. are that both COPD and CHF are relatively chronic problems and if this is truly the first time the pt has experienced dyspnea then I have to question both of them.

It's the "first time this has happened" that throws me. At least I'm reading this as being the first time anyway.

I'm not sure how "new onset" CHF presents, yes we have HTN, nocturnal dyspnea (presumably the first time though), negative for CP, and possibly cardiac asthma and he does smoke. But we have no hypertrophy on the 12 lead, we have dry lung sounds, we have no pedal edema.

I have doubts about this being "new onset" COPD also. As someone said no pursed lip breathing, no barrel chest, etc. Really the only thing pointing that way is the hx of smoking and once again it's an acute attack.

Now, someone stated that a PE doesn't increase the work of breathing. Based on a pt I ran recently I will respectfully disagree. Of course my guy had recent surgery and was SOB on scene and only wanted help from his car to the house. The guy appeared to be in distress but not overly so initially, color was good, able to talk in full sentences, no CP, in/out wheezes but diffuse. Within a few minutes - sats in the 80's, hypertensive and breathing like a freight train. This guy was using every acc muscle he had. Granted it turned out to be a massive PE - he later died before our little local hosp could get him flown out. But I no longer believe a PE doesn't cause acc muscle use. And the few PE's I've ran have usually been tachycardic.

It could always be an MI although we don't have much, if anything, at this time to confirm it. He has several contributing factors, smokes, overweight, HTN (we have no idea it this chronic HTN or related to the current problem - but it's likely to be chronic)

I agree with the theory that most of the tx I've read won't hurt the pt and some can be used to rule things out I suppose.

My tx:

O2, Monitor, IV, VS - Depending on time out/distance/other factors I want 12 leads every 5-10 minutes if possible.

CPAP is new here and I can only use it on "confirmed" CHF with pulmonary edema but I would have it ready in case things change.

Neb. bronchodilator - like some said it shouldn't hurt too much and if it doesn't help I can lean away from COPD and more toward cardiac issues.

Nitro (if we don't get significant relief from the neb tx) - Negative JVD, dry lung sounds and hypertension don't signal a RVI.

Any relief from the nitro I head down the MI/PE/CHF route. And if this guy has convinced me that this is truly a first time problem by now I'm really thinking MI/PE - in that order.

Have MS ready and play the MONA game...

So, did I kill the guy?

[CTXMEDIC]

Yes. Muhahahahahahha... :twisted:

about the PE and work of breathing. i hear ya but i gotta stand by what i previously posted. a PE in and of itself doesnt cause work of breathing. when i talk about the actual 'work' of breathing i am referring to, pulmonary edema, upper airway obstruction, or lower for that matter, stuff like that. in those cases the patient has to 'suck' more in order to get air past the obstruction. now of course when one gets fatigued from the breathing rate you'll start seeing accessory muscle usage. with a PE the o2 exchange is inhibited due to lack of blood flow to or from the lungs. the body attempts to compensate by increasing the rate and depth of breathing (remember all that PH balance stuff?). a CO poisoning patient does this as well. you ever see someone suck up a lung full of a fire extinguisher? same thing. theyre breathing like crazy but its to no avail. you also mentioned tachycardia. again, the good ol heart is trying to circulate what oxygen there is to other organs. by doing this the myocardial oxygen demand is increased and theres no oxygen. prepare for an arrest.

do you carry heparin?

[irme]

The history of this pt, including lifestyle and lack of GP checkups leads me to point towards LVF. It would appear this pt is suffering from left sided failure only due to the lack of JVD indicative of RVF. As we all know LVF is the most common form of heart failure and is usually followed by right sided failure later on. The wheezes are confusing as they could tend to make some people think respiratory; but as stated this could be (and I think is) just a cardiac wheeze, however with a few other S&S (see below) I would feel comfortable in my provisional diagnosis of CHF (L sided specifically).

Rule in LVF

- Axis deviation?

- Atrial enlargement? (p mitralie sp??)

Rule out COPD

As most probably know COPD is the suffering of asthma + empysemia or bronchitis (pink puffers/blue bloaters)

-Any productive coughs?

- mucus production/plugging?

- lung sounds ie ?decreased

This could still be a COPD but answers to the questions would help in fine tuning my treatment decision… The intresting vital sign here is the HR, it is not tachy which I would have expected for someone failing to be slightly tachy…

[vs-eh?]

Tx Plan:

CPAP

Monitor

IV access with a saline lock

.4mg SL nitro spray

re-assess

consider MS

id like to go farther with this but have questions about the patient.

Jesus dude, Anway...

All things considered, given the information...

Give him some oxygen and coach breathing

Monitor

IV

Re-assessment

trial +/- salbutamol (albuterol)

Unless there are any major changes, this is the most reasonable.

CPAP?

NTG

MORPHINE?

Ummmm... No.

Do people really think an ER doctor is going to be doing anything more (initially) based on the information provided than what I said? Chest X-ray's, blood work, MD assessment, etc...

Unless it is a truly acute and emergent case (which this does not appear to be, I mean like resuscitation case). Doctors do not start throwing down the over treatment. This is a differential diagnosis case that requires diagnostics that we cannot provide and is generally not based on clinical assessment.

[jwraider]

I'll put in my try, I'm also a new medic. I will make my answer true to what I would be likely to do even though it may not seem perfect or the right answer because I'm new.

This guy is presenting with respiratory distress. As he presents I would get his chief complaint (dyspnea) listen to his lungs (wheezing) and then ask PASTMED (progression, associated cp, sputum, talking words per sentance,medications, exertion, diagnosis?).

He would give the above answers which to me these answers stick out:

I don't see a doctor (possible untreated HTN or COPD)

It started while I was asleep (cardiac?)

I'm not diagnosed with anything (thanks for nothing)

It's hard to breath and I don't have chest pain or sputum

Using the equipment in my county I would turn on the monitor, attach the Sp02 (88%). Setup an Albuterol (5mg) Atrovent (0.5mg) treatment and place him on a nasal cannula with capnography. (I would look for a shark fin wave form although I imagine you do not have access to that info in this scenario. Shark fin = probable for bronchospasm http://emscapnography.blogspot.com ).

Then I would get a BP (210/90 hmmmmm....) while placing the ECG leads on and get an IV (maybe check blood sugar off the IV)

I would then move to transport and re-assess and go in depth with questioning.

Recent illness?

SAMPLE

Order of events should be clarified

Hx of heart problems? Lung problems? (smoker) Diabetes? HTN ? (I tend to go over those with patients here becaus emost have 1-4 of them! often untreated)

When did you last smoke?

My treatment plan is to see how the patient progresses both based on whatever is actually going wrong and if my interventions work or don't work.

This is the progression as needed:

02

Neb

CPAP with neb (we have those)

No epi due to BP, age and probable Hx of HTN

if CP develops treat with ASA and Nitro

I would do a physical exam on his chest initially (accessory muscles) and do a detailed physical as time allows mixed in with my other actions.

So my diagnosis would be respiratory distress secondary to smoking unless something else develops during the call (rhales, CP, EKG changes).

By the way is there any other abnormalities on the EKG? like LVH?

[CTXMEDIC]

Jesus dude, Anway...

All things considered, given the information...

Give him some oxygen and coach breathing

Monitor

IV

Re-assessment

trial +/- salbutamol (albuterol)

Unless there are any major changes, this is the most reasonable.

CPAP?

NTG

MORPHINE?

Ummmm... No.

Do people really think an ER doctor is going to be doing anything more (initially) based on the information provided than what I said? Chest X-ray's, blood work, MD assessment, etc...

Unless it is a truly acute and emergent case (which this does not appear to be, I mean like resuscitation case). Doctors do not start throwing down the over treatment. This is a differential diagnosis case that requires diagnostics that we cannot provide and is generally not based on clinical assessment.

Uh, what about it is 'over treatment'? I would consider you 'coaching' a sat of 88 percent with wheezing to breathe to be 'under treatment', but hey. unfortuantley we in the US dont have x'ray machines in our trucks yet. im sure your albuterol is going to do wonders for that MI you missed...and i said CONSIDER morphine. i also said that there was alot more i wanted to know about the patient. i appologize for 'over treating' my patient. :roll:

I also agree this patient needs care that we cannot provide but Im not going to stare at my patient and whisper soothing 'breathe baby breathe' into his ear enroute.

[sp121900]

Im gonna go with a pulmonary embolism.

Heres why (Keep in mind im just a first responder):

it is not CHF b/c theres no edema and no n/v

it is not an MI b/c theres no chest pain and theres nothing to mask any possible chest pain

i dont THINK its COPD b/c the pt isnt barrel chested and is not breathing through pursed lips

im unsure about it being a PE because theres no arrythmia (not that i would know what to do about that anyway).

what do you think?