simplified power point approach for medical student of clinical years

1. •5th year medical student tutorial session
•Dr: alsalheen alraied. MBChB
•Benghazi Medical Center

2. IMAGINE YOU ARE

3. Drowning !!
Imagine yourself sinking deep into the sea ,
ALONE , surrounded by darkness
Your heart beating fast ,
Laborious breathing ,
effortlessly and with pain
Feeling the end is near ,
Your hands looking pale
Trembling from fear
You are too breathless to speak or to shout for
help
When suddenly ………

4. SOMEONE SAVE YOU

6. Please note
ACUTE
DYSPNEA
IS EMERGENCY

7. Throwing a life jacket to the drowning patient

8. Case
You were called in the ER for managing a 62 year
old man , brought for sudden severe shortness
of breath , you found the patient sitting , leaning
forward and supporting his arms on a chairback
, looking distressed , pale , sweaty and coughing
productively of pink tinged frothy sputum . You
asked him some questions , but he was too
dyspneic and distressed to answer . But you
found past history of MI 6 months ago .

9. Case

10. Further examination
• Xanthelasma
• Pulse rate was 140 BPM
• RR : 30 cycles /min
• Spo2 was 85 %
• Blood pressure : 180 / 90 mmHg
• Basal crepitation
• Gallop rhythm
• Ankle edema bilaterally

11. Ask yourself
• Is the patient in respiratory distress ?
• Do you think additional investigations will do
any good ?
• Is the dyspnea cardiac or respiratory in origin
• What are your hints toward the cause ?

12. DDX of acute dyspnea
• Airway obstruction
• Tension PNX
• Anaphylaxis
• Arrhythmia with cardiac compromise
• Acute pulmonary edema
• Acute coronary syndrome
• Asthma exacerbation
• Respiratory tract infection
• Acute dyspnea in patient with COPD
NEED
IMMEDIATE
CORRECTION

13. Goals
• Main pathologies of pulmonary edema
• Causes of pulmonary edema
• What's important in history ?
• What to find in examination ?
• X-ray findings
• Other investigations
• Proper management

14. Being able to approach to such a case
You have to know the
basics

16. 3 factors important
• capillary hydrostatic pressure
• capillary oncotic pressure
• capillary – alveolar permeability

17. Pulmonary edema will develop if
• Increased capillary hydrostatic pressure
• Decreased capillary oncotic pressure
• Increased capillary – alveolar permeability
Usually the heart will act on the first factor
Oncotic pressure depends on albumin
3rd factor is influenced by lung causes

18. ...So
Pulmonary edema
Is either
cardiogenic
or
non cardiogenic

19. Cardiogenic edema
• Acute complication of MI and IHD
• Exacerbation of heart failure
• Arrhythmias
• Failure of prosthetic heart valve
• VSD
• Cardiomyopathy
• B-blockers
• Acute myocarditis
• Pericardial diseases

21. Non cardiogenic edema
• ARDS
• Intracranial
• Fluid overload
• Hypoalbuminemia (liver , renal , …)
• Drugs / poisons / chemical inhalation
• Lymphangitis carcinomatosis
• Smoke inhalation
• Near drowning incidents
• High altitude mountain sickness

23. What to get from history
Little but important
its good to search for :
Main symptoms: acute dyspnea , anxiety , pallor ,
sweating , orthopnea , productive cough .
Medical history: Previous heart diseases
(IHD , Failure …..) Respiratory illnesses
Surgical Hx: recent surgery (fluid overload) or valve
replacement surgeries
Drug Hx: -ve inotropics

24. Examination
• Tachypnea
• Tachycardia
• Anxiety
• Cyanosis ( if severe )
• coughing up frothy pink sputum
• Unable to talk
• Listen to the chest : murmurs , S3 /S4 , crackles (
either basal or widespread )
• JVP , ankle edema … signs of heart failure
• Sweating , pallor

25. Investigations
start treatment based on clinical suspicion before
completing all Ix .
• Attach cardiac monitor and check SpO2
• Obtain CXR
• Obtain ECG
• Send blood for U & E , glucose , CBC , troponins
• If severely ill or SpO2 < 94% get ABG
• Request previous notes on medical Hx

26. What to find in CXR
• Upper lobe diversion
• Cardiomegaly
• Kerley A or B lines
• Fluid in interlobar fissures
• Pleural effusions
• Bat wing hilar shadows

27. CXR mnemonic

28. CXR

34. Treatment
• sitting position
• High flow high concentration O2
• Give furosemide
• Give small doses of opioids I/V
(don’t give opioids to pt who are drowsy , confused
or exhausted as this may ppt. respiratory arrest )
• Give GTN iv or buccal GTN
• Dopamine may be needed to augment cardiac
function.

35. Treatment
• consider Foley , and monitor urine output
• treat underlying cause and associated
problems ( arrhythmia , MI , cardiogenic shock
, acute prosthetic valve failure )
• No response : CCU

37. Treating non-cardiogenic edema
Resuscitate with ABC
THEN
According to the underlying cause

38. Take home message
• Acute dyspnea is an emergency case
• Exclude causes that require immediate
correction (?)
• 3 main factors determine the cause of p. edema
• Differentiating cardiogenic from non-cardiogenic
is usually by history and its imp. In management
• Treatment should start before completing IX

39. THANKS
DON’T FORGET YOU ARE A HERO