Every Breath You Take – An Introduction to the Breathless Patient in the ED

Induction to EMBreathless patients are a challenge in the ED. Shortness of breath can be a frightening presenting complaint for both patients and doctors. As always, think about the possible life threatening causes and actively rule them out. For breathless patients think especially about:

  • Pneumonia
  • Asthma/COPD
  • Pulmonary Embolism
  • Acute left ventricular failure
  • Pneumothorax

 

 

Breathless Patients Podcast

In this podcast Iain and Simon discuss their approach to breathless patients in the ED which we hope will provide you with a good starting point.

 

 

For those of you who are more visual learners here is the video recorded a few years ago for SEMEP featuring our very own Iain Beardsell.

 

 

Take Home Points

  • Oxygen should be used in the patient with shortness of breath and the patient monitored closely. Hypoxia kills
  • Always rule out life threatening causes first
  • These patients are sick – do not be afraid to ask advice from a senior colleague early
  • Look for clues – you don’t have to wait until the penultimate page of the story to solve the mystery.

What have you learned about breathless patients?

[DDET Oxygen – or no oxygen??]
Oxygen administration is rarely a problem in the immediate and acute setting – and can save lives. So yes, when you first approach a patient who is short of breath, get that oxygen on while you make your assessment then think about the finer points of respiratory failure afterwards. [/DDET]

[DDET Where do I begin?]
A focused history, including asking the patient about previous conditions and whether they know what’s going on!
And then – initial assessment and examination including vital signs (especially respiratory rate), looking for clues as to the underlying cause of their breathlessness, remembering the five common causes. [/DDET]

[DDET What treatments might be useful?]
A small fluid bolus might help and carries relatively little risk; think about the need for nebulised bronchodilators for patients with asthma or COPD, and remember that antibiotics given early to patients with sepsis save lives.
If the patient has pain we should definitely treat that too.[/DDET]

[DDET Which investigations might help me find out more?]

  • A chest x-ray is often useful in patients who are short of breath; your ED seniors might be able to use bedside ultrasound to further ascertain the underlying pathology, so get help early!
  • ECGs are often useful in these patients
  • Blood gases can also provide lots of useful information – think carefully about whether you need arterial gases and if so, please use local anaesthetic.
  • If nothing makes sense – get a blood sugar, remembering that metabolic disease may cause an acidosis, presenting with an increased respiratory rate (although not often true dyspnoea).
  • And GET SENIOR HELP (including getting your seniors to assess you for those all-important workplace-based assessments; definitely start those early)[/DDET]

Other resources

Chest Radiographs

One of the key investigations in patients with shortness of breath is the humble chest radiograph. There are some phenomenal FOAM resources for interpretation of CXRs (along with other XRs) at Radiology Masterclass. Well worth bookmarking for your ED shifts (but do ask a senior if you’re unsure).

Chest X-Ray Anatomy  –  Chest X-Ray Abnormalities  –  Chest X-Ray Systematic Approach

Blood Gases

Think! Do you really need an ABG? If the answer is yes, please use local anaesthetic! Your patients will thank you…

Further Reading on Shortness of Breath

The Flipped EM Classroom – Shortness of Breath (with further links).

CEM Curriculum

SOB Curriculum-page-001SOB Curriculum-page-002

Posted by Natalie May

Dr. Natalie May, MBChB, MPHe, MSc, PGCert Medical Education, FRCEM, FACEM is section lead for paediatrics and medical education. She is an Editorial Board Member of the St Emlyn’s blog and podcast. She is a specialist in Emergency Medicine (Australia) and a Specialist in Emergency Medicine with Paediatric Emergency Medicine (UK). She works as Staff Specialist in Prehospital and Retrieval Medicine with the Ambulance Service of New South Wales (aka Sydney HEMS). She also works as aStaff Specialist, Emergency Medicine, St George Hospital (South Eastern Sydney Local Health District). Her research interests include medical education, particularly feedback; gender inequity in healthcare; paediatric emergency medicine. You can find her on twitter as @_NMay

  1. […] teach your new trainees the basics when Iain and Simon are so good at it? St. Emlyn’s offers an intro to the breathless patient and an introduction to headaches. This is a must listen series for those new to the ED. [AS, […]

    Reply

Thanks so much for following. Viva la #FOAMed

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