This case is written by Dr. Lindsey McMurray. She is a PGY4 Emergency Medicine resident from the University of Toronto who is currently doing a Resuscitation and Reanimation fellowship at Queen’s University.
Why it Matters
When the cause of acute respiratory distress is clear, its management can feel routine. However, as many senior physicians can attest, sometimes the cause is quite uncertain. It is important for junior learners to work through this differential because:
- Acute respiratory distress is a relatively common patient presentation
- Simultaneous initiation of investigations and treatment requires significant resource management skills
- Delays to treatment in the critically ill patient can lead to poor outcomes
You are on the Gynecology service and have been paged by the ward nurse to attend to a 78 year old woman who is having trouble breathing. She is POD #0 from a 4 hour TAH+BSO operation for ovarian CA. She just got to the ward about 1 hour ago. You enter the patient’s room she is hooked up to an IV with NS running at 150cc/hr.
A 78 year old woman post-op from a TAH+ BSO for ovarian CA has just been transferred to the ward when she develops acute shortness of breath. When the resident arrives, the patient is in significant respiratory distress saturating 80% on RA. Oxygen and medical therapy will not adequately relieve the patient’s distress. The resident will need to recognize that the patient has a Grade 3-4 LV and received 2L of fluid intra-operatively. When BiPAP is called for, it will be unavailable. Ultimately, the patient will require intubation.
ECG for case found here:
(ECG source: https://thejarvik7.files.wordpress.com/2012/02/inferior-wall-stemi-2005-05-27-08.jpg)
CXR for case found here:
(CXR source: https://www.med-ed.virginia.edu/courses/rad/cxr/pathology2chest.html)
This week’s case is written by Dr. Andrew Hall. He is an Assistant Professor in the Department of Emergency Medicine at Queen’s University where he is a Simulation-based Resuscitation Rounds Instructor and runs the Simulation-based OSCE Assessment Program for EM residents. He’s also one of the advisory board members here at EMSimCases.
Why it Matters
Acute asthma exacerbations are extremely common. Most asthmatics improve quickly after basic treatment with beta-agonists, anticholinergics, and steroids. This case highlights the management of those patients who don’t respond to the basics, including the following important points:
- Severe asthma requires immediate, continuous treatment
- Adjuncts to treatment such as magnesium sulfate, iv epinephrine, and bipap may be required
- Ventilation in a severe asthmatic is extremely challenging due to air trapping and the need for prolonged expiratory time
(vignette delivered by ER RN) A patient has been brought in by EMS and triaged to a Resuscitation Room in the Emergency Department with shortness of breath. He has had an upper respiratory tract infection with cough for 4 days. He’s now been having increasing SOB and chest tightness for 12 hours. He may have had a fever yesterday. EMS was called by a housemate who found him struggling to breathe at home. He is no longer responding to ventolin (using 4 puffs q30 min) and has rapidly worsened over the last hour. EMS reported vitals are HR 140, RR 41, O2Sat 85% on 100% O2 with face mask.
22 y.o. male is brought by EMS to the emergency department with increasing SOB and chest tightness x12 hours with rapid deterioration over the last hour resulting from a severe asthma exacerbation. He will require multiple pharmaceutical treatments, rapid sequence intubation and proper ventilation.
CXR for the case found here:
(CXR source: http://www.mypacs.net/cases/ACUTE-SEVERE-ASTHMA-ON-31-YO-CXR-3547838.html)