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ER26 Emergency Medicine
Approach to Common ED Presentations
Toronto Notes 2019
• admittedpatientsshouldgenerallyhaveaneurologyconsult
• patientshouldnotdriveuntilmedicallycleared(localregulationsvary)
■ complete notification form to appropriate authority regarding ability to drive
• warnregardingothersafetyconcerns(e.g.noswimming,bathingchildrenalone,etc.)
Shortness of Breath
• seeRespirology,R3andCardiologyandCardiacSurgery,C5
Table 18. Differential Diagnosis for Dyspnea
Respiratory
Cardiac Metabolic Neuromuscular Other
High Mortality/Morbidity
Airway obstruction (foreign body, epiglottitis, abscess, anaphylaxis)
Pneumo/hemothorax
Gas exchange –Pulmonary edema, PE, pneumonia, Acute exacerbations of COPD
CHF, MI, valvular disease, tamponade, arrhythmia Metabolic acidosis NYD, carbon monoxide inhalation Myasthenia gravis, diaphragmatic paralysis
Usually Less Emergent
Chronic obstructive, interstitial or restrictive lung disease
Pleural effusion
Chronic CHF, angina
Anemia, Hemoglobinopathy
CNS lesion, primary muscle weakness Anxiety, deconditioning
5 Types of Syncope
• Vasomotor • Cardiac
• CNS
• Metabolic
• Psychogenic
• acuteSOBisoftenduetoarelativelylimitednumberofconditions;associatedsymptomsandsignsare key to the appropriate diagnosis
■ substernal chest pain with cardiac ischemia
■ fever, cough, and sputum with respiratory infections ■ urticaria with anaphylaxis
■ wheezing with acute bronchospasm
■ environmental or occupational exposures
• dyspneamaybethesolecomplaintandthephysicalexammayrevealfewabnormalities(e.g.PE, pneumothorax)
• vitalsincludingpulseoximetry
■ wheeze and stridor (airway) vs. crackles (parenchymal), JVP, and murmurs
Investigations
• bloodwork
■ CBC and differential (hematocrit to exclude anemia), electrolytes, consider ABG/VBG ■ serial cardiac enzymes and ECG if considering cardiac source
■ Wells scores to consider appropriateness of D-dimer
• imaging
■ CXR (hyperinflation and bullous disease suggestive of obstructive lung disease, or changes in
interstitial markings consistent with inflammation, infection, or interstitial fluid)
■ CT chest usually is not indicated in the initial evaluation of patients with dyspnea, but can be
valuable in patients with interstitial lung disease, occult emphysema, or chronic thromboembolic disease (i.e. PE)
Management of Life-Threatening Dyspnea NYD
• seePrimaryandSecondarySurveys,ER2 • treatunderlyingcause
Disposition
• thehistoryandphysicalexamleadtoaccuratediagnosesinpatientswithdyspneainapproximately two-thirds of cases; the decision to admit or discharge should be based on the underlying disease process identified
■ consider intubation in CO2 retainers (e.g. COPD)
• ifdischarging,organizefollow-upandeducateregardingsignstoreturntohospital
Syncope
Definition
• sudden,transientlossofconsciousnessandposturaltonewithspontaneousrecovery
• usuallycausedbygeneralizedcerebralorreticularactivatingsystem(brainstem)hypoperfusion
Etiology
• cardiogenic:dysrhythmia,outflowobstruction(e.g.PE,pulmonaryHTN),MI,valvulardisease • non-cardiogenic:peripheralvascular(hypovolemia),vasovagal,cerebrovasculardisorders,CNS,
History and Physical Exam
metabolic disturbances (e.g. EtOH intoxication)