clinical problem solving when youre on call speaker: connie tomada, md
TRANSCRIPT
CLINICAL PROBLEM SOLVING WHEN YOU’RE
ON CALL
CLINICAL PROBLEM SOLVING WHEN YOU’RE
ON CALLSpeaker: Connie Tomada, MDSpeaker: Connie Tomada, MD
CLINICAL PROBLEM SOLVING WHEN YOU’RE
ON CALL
CLINICAL PROBLEM SOLVING WHEN YOU’RE
ON CALLHow to work-up and manage
Shortness of BreathHow to work-up and manage
Shortness of Breath
Shortness of BreathShortness of Breath
Cardiovascular CHF, PE
PulmonaryPneumonia, asthma,
COPD
Others anxiety, upper airway obstruction, ascites
Life-threatening hypoxia
Phone CallPhone Call
duration?
gradual or sudden?
cyanosis?
reason for admission?
presence of COPD or heavy smoking? (CO2 retainers)
oxygen order?
duration?
gradual or sudden?
cyanosis?
reason for admission?
presence of COPD or heavy smoking? (CO2 retainers)
oxygen order?
Phone CallPhone Call
Oxygen
1 L/min O2 on NC adds 3% FiO2 on RA
for CO2 retainers, start with 3-4 L/min, FiO2 29-32%
for asthma/COPD, aerosol treatment
ABG?
Oxygen
1 L/min O2 on NC adds 3% FiO2 on RA
for CO2 retainers, start with 3-4 L/min, FiO2 29-32%
for asthma/COPD, aerosol treatment
ABG?
Travel TimeTravel Time
Cardiovascular CHF, PE
PulmonaryPneumonia, asthma,
COPD
Others anxiety, upper airway obstruction, ascites
Life-threatening hypoxia
Travel TimeTravel Time
Cardiovascular CHF, PE
PulmonaryPneumonia, asthma,
COPD
Others anxiety, upper airway obstruction, ascites
Life-threatening hypoxia
BedsideBedside
rapid visual assessment (sick or critically ill?)
ABG, O2, IV access & IV fluids, ECG
crash cart and ECG monitor
code status if considering intubation (call senior resident/ICU attending)
rapid visual assessment (sick or critically ill?)
ABG, O2, IV access & IV fluids, ECG
crash cart and ECG monitor
code status if considering intubation (call senior resident/ICU attending)
BedsideBedside
ABCs and Vital signs
airway obstruction
RR<12/min: narcotic OD, cushing sign
paradoxical breathing
fever: infection vs. PE
pulsus paradoxus: asthma, COPD, cardiac tamponade
ABCs and Vital signs
airway obstruction
RR<12/min: narcotic OD, cushing sign
paradoxical breathing
fever: infection vs. PE
pulsus paradoxus: asthma, COPD, cardiac tamponade
BedsideBedside
Hypoxia (O2sat<92% or PaO2<60 mmHg)
increase oxygen support until O2 sat >92%
careful with CO2 retainer (COPD, heavy smoker), O2sat ~90%
nasal cannula face mask venturi mask non-rebreather dual flow BiPap endotracheal intubation
repeat ABG
Hypoxia (O2sat<92% or PaO2<60 mmHg)
increase oxygen support until O2 sat >92%
careful with CO2 retainer (COPD, heavy smoker), O2sat ~90%
nasal cannula face mask venturi mask non-rebreather dual flow BiPap endotracheal intubation
repeat ABG
BedsideBedside
Hypoxia (O2sat<92% or PaO2<60 mmHg)
increase oxygen support until O2 sat >92%
careful with CO2 retainer (COPD, heavy smoker), O2sat ~90%
nasal cannula face mask venturi mask non-rebreather dual flow BiPap endotracheal intubation
repeat ABG
Hypoxia (O2sat<92% or PaO2<60 mmHg)
increase oxygen support until O2 sat >92%
careful with CO2 retainer (COPD, heavy smoker), O2sat ~90%
nasal cannula face mask venturi mask non-rebreather dual flow BiPap endotracheal intubation
repeat ABG
BedsideBedside
Hypoxia (O2sat<92% or PaO2<60 mmHg)
increase oxygen support until O2 sat >92%
careful with CO2 retainer (COPD, heavy smoker), O2sat ~90%
nasal cannula face mask venturi mask non-rebreather dual flow BiPap endotracheal intubation
repeat ABG
Hypoxia (O2sat<92% or PaO2<60 mmHg)
increase oxygen support until O2 sat >92%
careful with CO2 retainer (COPD, heavy smoker), O2sat ~90%
nasal cannula face mask venturi mask non-rebreather dual flow BiPap endotracheal intubation
repeat ABG
BedsideBedside
Hypoxia (O2sat<92% or PaO2<60 mmHg)
increase oxygen support until O2 sat >92%
careful with CO2 retainer (COPD, heavy smoker), O2sat ~90%
nasal cannula face mask venturi mask non-rebreather dual flow BiPap endotracheal intubation
repeat ABG
Hypoxia (O2sat<92% or PaO2<60 mmHg)
increase oxygen support until O2 sat >92%
careful with CO2 retainer (COPD, heavy smoker), O2sat ~90%
nasal cannula face mask venturi mask non-rebreather dual flow BiPap endotracheal intubation
repeat ABG
BedsideBedside
Hypoxia (O2sat<92% or PaO2<60 mmHg)
increase oxygen support until O2 sat >92%
careful with CO2 retainer (COPD, heavy smoker), O2sat ~90%
nasal cannula face mask venturi mask non-rebreather dual flow BiPap endotracheal intubation
repeat ABG
Hypoxia (O2sat<92% or PaO2<60 mmHg)
increase oxygen support until O2 sat >92%
careful with CO2 retainer (COPD, heavy smoker), O2sat ~90%
nasal cannula face mask venturi mask non-rebreather dual flow BiPap endotracheal intubation
repeat ABG
BedsideBedside
Hypoxia (O2sat<92% or PaO2<60 mmHg)
increase oxygen support until O2 sat >92%
careful with CO2 retainer (COPD, heavy smoker), O2sat ~90%
nasal cannula face mask venturi mask non-rebreather dual flow BiPap endotracheal intubation
repeat ABG
Hypoxia (O2sat<92% or PaO2<60 mmHg)
increase oxygen support until O2 sat >92%
careful with CO2 retainer (COPD, heavy smoker), O2sat ~90%
nasal cannula face mask venturi mask non-rebreather dual flow BiPap endotracheal intubation
repeat ABG
BedsideBedside
Hypoxia (O2sat<92% or PaO2<60 mmHg)
increase oxygen support until O2 sat >92%
careful with CO2 retainer (COPD, heavy smoker), O2sat ~90%
nasal cannula face mask venturi mask non-rebreather dual flow BiPap endotracheal intubation
repeat ABG
Hypoxia (O2sat<92% or PaO2<60 mmHg)
increase oxygen support until O2 sat >92%
careful with CO2 retainer (COPD, heavy smoker), O2sat ~90%
nasal cannula face mask venturi mask non-rebreather dual flow BiPap endotracheal intubation
repeat ABG
BedsideBedside
Hypoxia (O2sat<92% or PaO2<60 mmHg)
increase oxygen support until O2 sat >92%
careful with CO2 retainer (COPD, heavy smoker), O2sat ~90%
nasal cannula face mask venturi mask non-rebreather dual flow BiPap endotracheal intubation
repeat ABG
Hypoxia (O2sat<92% or PaO2<60 mmHg)
increase oxygen support until O2 sat >92%
careful with CO2 retainer (COPD, heavy smoker), O2sat ~90%
nasal cannula face mask venturi mask non-rebreather dual flow BiPap endotracheal intubation
repeat ABG
BedsideBedside
Hypoxia (O2sat<92% or PaO2<60 mmHg)
increase oxygen support until O2 sat >92%
careful with CO2 retainer (COPD, heavy smoker), O2sat ~90%
nasal cannula face mask venturi mask non-rebreather dual flow BiPap endotracheal intubation
repeat ABG
Hypoxia (O2sat<92% or PaO2<60 mmHg)
increase oxygen support until O2 sat >92%
careful with CO2 retainer (COPD, heavy smoker), O2sat ~90%
nasal cannula face mask venturi mask non-rebreather dual flow BiPap endotracheal intubation
repeat ABG
Intubation???Intubation???12<RR>30/min
inability to protect airway
change in MS
paradoxical breathing
pH<7.35
normal pH with tachypnea
PaO2<60
PCO2>50
Full Code
when you think it’s needed
12<RR>30/min
inability to protect airway
change in MS
paradoxical breathing
pH<7.35
normal pH with tachypnea
PaO2<60
PCO2>50
Full Code
when you think it’s needed
Causes of Shortness of Breath
Causes of Shortness of Breath
A quick reviewA quick review
Acute CHFAcute CHF
Hx of CHF or cardiac disorder, orthopnea/PND, + I/O, weight gain
signs of fluid overload (JVD, insp crackles +/- pleural effusion, systolic murmurs, + HJR, edema)
chest xray
decrease preload: sit patient up, oxygen, furosemide, NTG, morphine
look for cause of CHF
Hx of CHF or cardiac disorder, orthopnea/PND, + I/O, weight gain
signs of fluid overload (JVD, insp crackles +/- pleural effusion, systolic murmurs, + HJR, edema)
chest xray
decrease preload: sit patient up, oxygen, furosemide, NTG, morphine
look for cause of CHF
Causes of CHFCauses of CHFCAD
HTN
valvular heart disease
cardiomyopathies
pericardial disease
MI
Fever, infection
dysrhythmia
PE
NSAIDS
anemia
CAD
HTN
valvular heart disease
cardiomyopathies
pericardial disease
MI
Fever, infection
dysrhythmia
PE
NSAIDS
anemia
Pulmonary EmbolismPulmonary EmbolismTachypnea, tachycardia and chest pain, Virchow’s triad (e.g. hypercoagulable state, immobility, vein injury), History of DVT
Pleural rub, pleural effusion, lower extremity with edema/palpable cord/calve tenderness
Stat ECG (S1Q3T3), stat CXR, stat CTA chest, echo, LE Doppler, d-dimer
Heparin vs LMWH, IVC filter, thrombolysis if in shock (call senior resident)
ICU transfer if with low oxygen saturation +/- intubation
Tachypnea, tachycardia and chest pain, Virchow’s triad (e.g. hypercoagulable state, immobility, vein injury), History of DVT
Pleural rub, pleural effusion, lower extremity with edema/palpable cord/calve tenderness
Stat ECG (S1Q3T3), stat CXR, stat CTA chest, echo, LE Doppler, d-dimer
Heparin vs LMWH, IVC filter, thrombolysis if in shock (call senior resident)
ICU transfer if with low oxygen saturation +/- intubation
PneumoniaPneumonia
cough productive of purulent sputum, fever/chills, pleurisy, +/- immunocompromised
leukocytosis, bandemia, CXR
sputum GS/CS, Strep/Mycoplasma/Legionella Ag, blood culture
antibiotics (refer to guidelines)
cough productive of purulent sputum, fever/chills, pleurisy, +/- immunocompromised
leukocytosis, bandemia, CXR
sputum GS/CS, Strep/Mycoplasma/Legionella Ag, blood culture
antibiotics (refer to guidelines)
Bronchospasm (Asthma/COPD)Bronchospasm (Asthma/COPD)
tobacco abuse, steroid use, intubation history, precipitating factors, anaphylaxis
diffuse wheezing, prolonged expiration, loud P2
somnolence, pulsus paradoxus, cyanosis, accessory muscle
CXR, ABG, spiromtery, pulse ox
oxygen, aerosols, steroid, antibiotics
tobacco abuse, steroid use, intubation history, precipitating factors, anaphylaxis
diffuse wheezing, prolonged expiration, loud P2
somnolence, pulsus paradoxus, cyanosis, accessory muscle
CXR, ABG, spiromtery, pulse ox
oxygen, aerosols, steroid, antibiotics
Always remember...Always remember...
Call your senior resident if you need some assistance.
Perform proper hand-offs and sign-out
Call your senior resident if you need some assistance.
Perform proper hand-offs and sign-out
CLINICAL PROBLEM SOLVING WHEN YOU’RE
ON CALL
CLINICAL PROBLEM SOLVING WHEN YOU’RE
ON CALL
• How to work-up and manage
• Shortness of Breath
• How to work-up and manage
• Shortness of Breath