Case Presentation Aaron Sibley PGY 3 Emergency Medicine

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

Learn two “take-home” messages.

Help us all look as smart as Rob 2 .

Have fun with an interesting case.

“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.

“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.

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 O 2 monitor.

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 O 2 monitor.

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.

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.

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.

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.

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.

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.

Treatment/Investigations: R3: What tx, what tests/investigations? Answer: Tx: 3 back-to-back masks (Ventolin 5mg/Atrovent 500ug), IV steroids (125mg Methylprednisilone), MgSO 4 (2g over 20 mins) Inv/tests: CBC,Lytes, BUN/Cr, CXR (portable), EKG, ABG, peak flow.

R3: What tx, what tests/investigations?

Answer: Tx: 3 back-to-back masks (Ventolin 5mg/Atrovent 500ug), IV steroids (125mg Methylprednisilone), MgSO 4 (2g over 20 mins) Inv/tests: CBC,Lytes, BUN/Cr, CXR (portable), EKG, ABG, peak flow.

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.

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.

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.

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.

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).

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).

CXR: Back

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

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

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?

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?

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

1) Hypoxia

2) CO2 level

3) Heavy smoker

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

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

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

Anyone: Name 3 cognitive errors that were made in this case?

1) Diagnosis momentum

2) Symptom cueing

3) Anchoring

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 CO 2 ), 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.

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 CO 2 ), 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.

Pulmonary Function Tests: Back 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

Questions?

“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.

“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.