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Housestaff Survival Guide | Crosscover | Shortness of Breath
On the phone:
Get full vitals; onset of SOB; underlying diseases; order oxygen if hypoxic (avoid too much oxygen in CO2 retainers), nebs, ECG,
ABG kit to bedside and go see pt now
Hx
sudden onset (PE, PTX, pulmonary edema) vs. gradual onset (pneumonia, COPD/asthma exacerbation, pulm edema or effusion),
h/o lung or heart disease, associated sx (cough, hemoptysis, fever, chest pain), risk factors for PE or MI
PE:
vitals, use of accessory muscles, midline trachea, signs of cyanosis, JVP, lungs, heart, loud P2, RV heave, edema, mental status
(confused, drowsy)
Tests:
ABG, CXR, EKG, CBC; Consider high-resolution Chest CT with PE protocol (if kidneys can tolerate dye – pre-hydrate with
IVF unless overloaded). Consider Visipaque contrast for high-risk nephropathy. Patient will need 18
gauge IV access for the contrast dye (often can’t use PICC). Generally, can’t get V/Q scans at
night/weekends (that goes for both VA & UIC).
Other: anxiety/pain/opiates/narcotics
Do not miss:
Hypoxia – insufficient tissue oxygenation (look at PO2 – assuming it’s not venous!);
Anaphylaxis (wheezing, itch/urticaria, hypotension)
Management:
-supplemental oxygen (NC, face mask, NRFM, BiPAP 10/5)
-Albuterol/Ipratropium nebs
-Lasix if fluid overloaded, CHF exacerbation (Lasix 40mg IV, if no response, double the dose every 1 hour, e.g. 40mg, 80mg,
160mg, …and consider adding metolazone 2.5mgPO)
-check peak flows if asthma; sputum culture
-if narcotic overdose, give naloxone 0.2 to 2mg IV
-Anaphylaxis tx: Epi (0.3cc of 1:1000epi SC or 3cc of 1:10000epi IV), Hydrocortisone 250mg
IVPB, Benadryl 25-50mg IVPB, Famotidine
Indications for Intubation?
Look for rapid shallow breathing and fatigue. Try to reverse underlying conditions.
1) airway protection 2) decline in mental status 3) pCO2 increasing 4) pO2 < 60, not responding to
supp oxygen 5) pH 50 with pH