Dyspnea

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//Badum-bum-bum. Badum-bum-bum.// //'Ugh, did someone change the ring-tone again?!'// you mumble as you search your pockets for the Rapid Response phone. //'RRT, this is---'// <<textbox "$name" "Type your name and hit enter" "Start" autofocus>>

//'RRT. This is $name speaking.'// //'Hey, $name. I got a patient here in 3129 who isn't looking too hot. I think you should make your way over here.'// It's Scones, one of the seasoned Rapid Response nurses. //'What's going on?'// //'He's altered and pretty tachypneic. I think you should come check him out.'// Not long after you hang up, your walk over to the 3rd floor is interrupted by a buzz from your pager. //RAPID RESPONSE TEAM TO ROOM 3129.// //Man, I was already on my way...// As you arrive onto the ward, you can hear Scones' voice from inside the patient's room. You decide to: [[Enter Room 3129 and evaluate the patient|Patient Evaluation]] [[Stop outside the room and review the patient's chart|EMR]] [[Get a report from the patient's RN|Nurse Report]]

//'Hey, what's going on?'// you ask as you enter Room 3129. //'Not sure, Doc, but he's not doing too well,'// replies Scones. //'Nurse was saying that he just got up here from the E.R. He's breathing in the 40s, sounds like crap. BP's low. Getting repeat vitals now.//' You turn to the bed where you see a mid-60s year-old male in notable respiratory distress with abdominal breathing. He appears awake, but is lethargic and moaning continuously. He's breathing rapidly with laboured, shallow respirations. A quick auscultation of his lungs reveals significantly diminished air entry in all fields without wheezing, crackles, or rales. His heart sounds are tachycardic and regular. Feeling for a pulse, you notice that he is diaphoretic and hot to the touch. He is not following commands and does not answer your questions. //'Sats are dropping, $name,'// affirms Scones as he points to the crimson red numbers on the vitals monitor. 86%, it says, on 3 L/min of O2 via nasal cannula. Blood pressure is 85/40. Heart rate is 120 and remains regular. //'I'm giving him a 1 litre bolus of normal saline,'// affirms Scones. You nod in approval. <<textarea "$answer1" "What other interventions could be the best next steps for this patient (medications, imaging, labs, etc)?" autofocus>> <<button [[Type in your answer, then click here to advance|Patient Evaluation 2]]>><</button>>

You log in to the EMR and open the patient's chart. He is a 69 year-old male with a PMHx of heart failure with reduced ejection fraction (38%), COPD with chronic hypoxemia (documented as using 3-4 L via nasal cannula), coronary artery disease, and type 2 diabetes mellitus. He presented to the emergency department with a chief complaint of dyspnea and cough. A chest X-ray revealed bilateral lower lobe infiltrates. The admitting residents have started treatment for community-acquired pneumonia, sepsis, and acute renal failure. Upon reading all of that you transition to the results page to review his lab results and charted vitals. Waiting for the results to load, your thoughts are interrupted by Scones, still in the patient's room. //'DOC, I NEED YOU IN HERE!'// yells Scones. Before you have a chance to see any results you hear the ward's CODE BLUE alarm fire. It's the patient in Room 3129. You rush into the room to help Scones with CPR. //'Where were ya, Doc?!'// he asks. After 5 minutes of high-quality CPR and ACLS protocol, spontaneous circulation returns and the patient is triaged to the medical ICU for further care. -----END OF SCENARIO----- [[Click here to read the conclusion|Conclusion]]

//'Hey, I got a call from Scones about your patient. What's going on?'// you ask the patient's nurse. //'I don't know. He just got up here from Emergency a few hours ago. He doesn't look too good,'// she replies. //'How have his vitals been?'// you ask as the nurse turns her computer screen towards you. You scroll through the results review screen to see that Emergency Department staff have charted normal vitals since the patient's arrival. //'Hmm, are his labs o---.'// //'DOC, I NEED YOU IN HERE!'// yells Scones from the room. Before you have a chance to finish your question you hear the ward's CODE BLUE alarm fire. It's the patient in Room 3129. You rush into the room to help Scones with CPR. //'Where were ya, Doc?!'// he asks. After 5 minutes of high-quality CPR and ACLS protocol, spontaneous circulation returns and the patient is triaged to the medical ICU for further care. -----END OF SCENARIO----- [[Click here to read the conclusion|Conclusion]]

In bed is a mid-60s year-old male in notable respiratory distress with abdominal breathing. He appears awake, but is lethargic and moaning continuously. He's breathing rapidly with laboured, shallow respirations. A quick auscultation of his lungs reveals significantly diminished air entry in all fields without wheezing, crackles, or rales. His heart sounds are tachycardic and regular. Feeling for a pulse, you notice that he is diaphoretic and hot to the touch. He is not following commands and does not answer your questions. //'Sats are dropping, $name,'// affirms Scones as he points to the crimson red numbers on the vitals monitor. 86%, it says, on 3 L/min of O2 via nasal cannula. Blood pressure is 85/40. Heart rate is 120 and remains regular. //'I'm giving him a 1 litre bolus of normal saline,'// affirms Scones. You nod in approval. Upon review of his chart, you see that he is FULL CODE. Which of the following is the best next step for the patient? [[Administer oxygen through a non-rebreather mask and obtain STAT arterial blood gases|ABG]] [[Page anaesthesia for STAT endotracheal intubation|Intubation]] [[Order a STAT Chest X-Ray prior to deciding on management|CXR]] ---------- //For your reference, here's what you were already considering: $answer1//

An arterial blood sample obtained while the patient is wearing a non-rebreather oxygen mask reveals the following: * pH: 7.10 (normal 7.35-7.45) * pCO2: 52 mmHg (normal 35-45) * pO2 395 mmHg (normal 75-110) * HCO3: 13.1 mMol/L (normal 22-26) * Total CO2: 13.8 mMol/L (normal 23-27) * O2 Saturation: 100% (normal >94%) * Lactate: 7.1 mMol/L (normal 0.5-2.2) * Base Excess: -14.2 mMol/L (normal -2-2) <<textbox "$ABG" "What is your diagnosis?" ABG2 autofocus>> Type in your interpretation of these ABGs and hit Enter.

Anaesthesia is paged overhead and you receive a call. //Badum-bum-bum. Badum-bum-bum.// //'RRT. This is $name.'// You fill them in and soon after the intubation team arrives to the room. The patient is intubated with successful colour change on the capnometric analyzer thereafter. The respiratory therapy team attaches the patient to a ventilator with positive end-expiratory pressure of 8 and a repeat set of vitals reveals pulse oximetry of 95% on 60% FiO2. Following infusion of 1 litre of 0.9% saline, repeat blood pressure is 105/65. //'Good call, Doc. I think he needed it,'// says Scones. After calling your colleagues in the medical ICU, the patient is transported to the critical care ward for ongoing care. -----END OF SCENARIO----- [[Click here to read the conclusion|Conclusion]]

You order a STAT portable Chest X-Ray. //'Do you want to get gases?'// urges Scones. //'No, let's get some pictures first.'// //'Alright, we should call X-ray then.'// As you wait for them to arrive, Scones connects the patient to an AED. As he attaches the second pad to the patient's chest, you notice that the patient has now become bradycardic, with heart rate in the 30s. //'Ah shit,'// says Scones as he feels for a carotid pulse. //'Weak carotid, Doc.'// Motioning to the patient's nurse, he commands, //'Quick, get the backboard!'// In a flash, you hear the ward's CODE BLUE alarm fire. Scones starts chest compressions. After 5 minutes of high-quality CPR and ACLS protocol, spontaneous circulation returns and the patient is triaged to the medical ICU for further care. -----END OF SCENARIO----- [[Click here to read the conclusion|Conclusion]]

An arterial blood sample obtained while the patient is wearing a non-invasive positive pressure ventilation mask (PEEP 8, FiO2 100%) reveals the following: * pH: 7.10 (normal 7.35-7.45) * pCO2: 52 mmHg (normal 35-45) * pO2 395 mmHg (normal 75-110) * HCO3: 13.1 mMol/L (normal 22-26) * Total CO2: 13.8 mMol/L (normal 23-27) * O2 Saturation: 100% (normal >94%) * Lactate: 7.1 mMol/L (normal 0.5-2.2) * Base Excess: -14.2 mMol/L (normal -2-2) These findings are consistent with concurrent metabolic and respiratory acidosis. Here's what you thought: $ABG. Following these findings, what is the next best step? [[Start non-invasive positive pressure ventilation|BiPAP]] [[Page anaesthesia for STAT endotracheal intubation|Intubation]] [[Order a STAT Chest X-Ray prior to deciding on management|CXR2]]

You ask the respiratory therapist to bring in a non-invasive positive pressure ventilation machine. The mask is applied to the patient. Shortly after, the patient's mental status worsens. He is now unresponsive. Repeat vital signs reveals bradycardia with heart rate in the 30s. Blood pressure is 70/30. //'Ah shit,'// says Scones as he feels for a carotid pulse. //'Weak carotid, Doc.'// Motioning to the patient's nurse, he commands, //'Quick, get the backboard!'// In a flash, you hear the ward's CODE BLUE alarm fire. Scones starts chest compressions. After 5 minutes of high-quality CPR and ACLS protocol, spontaneous circulation returns and the patient is triaged to the medical ICU for further care. -----END OF SCENARIO----- [[Click here to read the conclusion|Conclusion]]

You order a STAT portable Chest X-Ray. As you wait for them to arrive, Scones connects the patient to an AED. As he attaches the second pad to the patient's chest you notice that the patient has now become bradycardic, with heart rate in the 30s. //'Ah shit,'// says Scones as he feels for a carotid pulse. //'Weak carotid, Doc.'// Motioning to the patient's nurse, he commands, //'Quick, get the backboard!'// In a flash, you hear the ward's CODE BLUE alarm fire. Scones starts chest compressions. After 5 minutes of high-quality CPR and ACLS protocol, spontaneous circulation returns and the patient is triaged to the medical ICU for further care. -----END OF SCENARIO----- [[Click here to read the conclusion|Conclusion]]

Hey, $name! I hope you enjoyed this clinical scenario and that it has you thinking about similar real-life scenarios. This case is reflective of many challenges we face in Rapid Response settings. Specifically, this case exemplifies the challenge in appropriately escalating care and preventing further decompensation while knowing very little about the patient. A few points to consider: * When responding to Rapid Response calls, it is important to evaluate the patient as soon as feasible. Charted history elements, lab and imaging results, and bystander reports are important but matter very little when the patient is in critical condition and is requiring basic life support (BLS) or advanced cardiac life support (ACLS). Our role in these situations can be pivotal to a patient's outcome--it is <b>always</b> best to start at the bedside. * Respiratory distress is a clinical scenario that often worsens rapidly. It's important to be vigilant and think as many steps ahead as possible. Through this lens, consider whether or not an intervention, test, or lab is going to significantly influence your patient's immediate outcome or management. Is it worth the time and risk? Can you transport your patient for the test effectively? Would it be better to simply intervene as best as possible? * CO2 Narcosis in Respiratory Acidosis can worsen rapidly. Choosing the most appropriate modality of ventilation at the appropriate time can drastically improve a patient's outcome. Be sure to remain cognisant of common barriers to successful non-invasive ventilation, such as worsening mental status, acute vomiting, and profuse cough (to name a few). //Written and edited by Amreet Sidhu, MD. Edited and reviewed by Katie Zechar, MD.//