Shortness of breath

[Acosell]

You're sitting in the diner waiting for your food. You see the waitress come out of the back with your plates of food. Your mouth waters. Your pager beeps.

Dispatched lights and sirens to a local apartment for a man suffering shortness of breath.

Scene is safe, no evidence of danger

No evidence of a traumatic injury

One patient

Your patient is an elderly male sitting in the tripod position in an armchair, as you approach, you note sternal indrawing and accessory muscle use. You perform your primary assessment:

Airway - Patent

Breathing - Extremely laboured, 1 word dyspnea, and worsening. Auscultation reveals wheezes in all fields, diminished in the bases.

Circulation - Pts. radial pulse is strong, regular, and rapid.

Your partner has gotten a set of vitals for you:

Pulse: 112 Regular, Strong

Respirations: 30 Regular, Shallow

Blood Pressure: 152/98

Sp02: 89%

Skin: Pale, Cool, Wet

Pupils: Equal and Reactive.

Your attempts to gather a history fail: The patient can't catch his breath long enough to speak.

Take it away folks!

[akroeze]

Our protocol?

Ventolin MDI with spacer 9 puffs repeat up to three sets prn

if he can't take the MDI:

Ventolin 5.0mg Neb x3 prn

Rapid x-port

Of course, I would want a rhythm strip as well.

[aussiephil]

our protocol for this is a mix of Ventolin & iprtroprium bromide with O2 as the dive gas @ 8 litres per minute initially.

This pt will be tired & may need some assistance with expiration so consideration would be gien with this.

Also this pt is heading to extremis & adrenaline would also need to be considered especially if there is no improvement with initial Rx.

The pt would need to be sitting & monitored continually.

This pt would then be transported urgently to difinitive hospital care.

Take care.

[SooC]

Would there be a consideration for epi for exacerbated asthma at all?

Assesment finding seem a bit concerning- 1 word dyspnea and worsening, 30 breaths/min, use of accessory muscles, 89% sats...

If there is no history of asthma- just keep trying the ventolin (hoping your service has an nebulizer- there is no severe respiratory illness outbreak and the pt does not have a fever over 38 degrees C- may be easier to use with the pt than an MDI)

If there is a history of asthma....

Conditions:

-under 50 years old

-simply 'yes/no' question for a history of asthma would tell you if he fits under that protocol- or medic alert bracelet indicating asthma

-"any pt with severe SOB from a suspected asthma exacerbation AND requires ventilatory support via BVM and/ or severe agitation, confusion, and cyanosis" So if they dont need or tolerate a BVM- may still administer epi based on the agitation, confusion and cyanosis if present.

= 0.01 mg/kg SC (rounded to the nearest 0.05) to a max dose of 0.3 mg

Sounds like he needs more than ventolin...but Ive only used the ventolin/epi protocols in scenerio-land so who knows. Correct me if Im wrong- better now than after my final practical scenerio

[Acosell]

Patient is definately over 50, so no epi.

You start the protocol. After six puffs of ventolin, the patient refuses. He says he's feeling a little better (although he still has 3 word dyspnea).

Your partner started the ECG at the same time you start your protocol.

They finish shortly after the patient refused ventolin.

Sinus Tach.

All of the sudden, your patient says it's getting worse, and lapses into 1 word dyspnea.

You reassess.

Airway: Patent

Breathing: Laboured still, auscultation reveals... fine crackles in all fields, still diminished in the bases

Vitals are:

Pulse: 116 Regular, Strong

Respirations: 30 Regular, Shallow

Blood Pressure: 156/100

Sp02: 94% on 15lpm

Skin: Pale, Cool, Wet

Pupils: Equal and Reactive.

Course of action?

What went wrong?

[SooC]

Oops, so I missed the "elderly" part :oops:

[TechMedic05]

Sounds like an instance of "Cardiac Asthma", or beginnings of CHF, and the albuterol helped 'push him over the edge', per se. Although some initial relief from the bronchoconstriction from irritation of some fluid buildup, the CHF has worsened.

He may not be able to answer, is there anyone else on scene who may be able to help with HPI? Good to know he's afebrile.

Any hints based on scars? medications lists, or bottles? Any response to 'Cardiac history?'

I'd discontinue albuterol, change to a high concentration oxygen, ensure position is upright, and go ahead with some nitro SL.

Considerations - Have we established IV Access? EKG? Consideration of a 12 lead fairly rapidly might be a good idea.

Continue with nitro SL, Furosemide 1 mg/kg, thereabouts. Or double his normal dose. Consideration of Morphine 2-4 mg IV, repeated per local protocol.

Reassess the patient between treatments, and go from there. It's a start.

[ncmedic309]

You begin treating the patient for reactive airway disease/COPD and realize that it's actually a cardiac issue, you change your course of treatment. I hate the term "treat and trash", but sometimes it happens and there's not much you can do about it. Your patient presents one way, you can't get a better history, you have to treat what you see. Just be sure to reassess for changes. If it starts looking like something else, discontinue your original care and begin your new treatment modality. It seems this patient began presenting like your classic COPD/Asthma case, and then heart failure showed it's nasty face...

As far as further treatment, nitrates, diuretic, and CPAP. If the patient has a hx of COPD (more specifically emphysema) make sure you have the ability to lower your cm H2O (pressure range) so you don't "pop" any blebs when using a CPAP machine...

[akroeze]

Pt no longer meets any symptom relief protocols and thus is a load and go. IIRC they should be coarse, wet crackles for Nitro.

[TechMedic05]

So, just because a patient does not completely fit perfectly into a patient care protocol we can no longer do anything for them...Well, short of driving really, really, really, often unnecessarily fast?