Patients with “shortness of breath” are a challenge in the ED. Shortness of breath can be a frightening presenting complaint for both patients and doctors. When you think about it, it represents the body struggling to get enough oxygen, and whatever the cause that’s a bad thing.
As always, think about the possible life threatening causes and actively rule them out. For breathless patients think especially about:
- Pulmonary Embolism
- Acute left ventricular failure
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.
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?
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.
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.
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.
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)
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
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).
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