Question Of The Day #90

question of the day
366 - pneumonia-middle lobe

Which of the following is the most likely cause of this patient’s condition?

Shortness of breath, also known as dyspnea, is a common reason for patients to visit the Emergency Department.  Dyspnea is often caused by a pulmonary or cardiovascular condition, but it is important to remember that dyspnea can be due to endocrine conditions, toxicologic conditions, neurologic conditions, hematologic conditions, musculoskeletal conditions, and psychiatric conditions. 

The initial approach to all patients with shortness of breath involves the primary survey, or “ABCs” (Airway, Breathing, Circulation).  This first involves checking the patient for a patent airway.  A simple method to assess the airway is to ask the patient to speak and listen for the voice.  A muffled voice, the presence of stridor, hematemesis, or a lethargic patient are clues that a patent airway may not be present.  Problems with the airway, such as an obstructing foreign body, inflammation (i.e., epiglottitis, anaphylactic shock), or vocal cord dysfunction can certainly cause shortness of breath.  Endotracheal intubation may need to be performed before moving forward.  Breathing is assessed by evaluating the function of the lungs.  Steps include looking at how the patient is breathing (fast or slow), measurement of an SpO2 level, and auscultation of both lungs for wheezing, crackles, rhonchi, or distant or absent sounds.  A low oxygen level should be immediately addressed with supplemental oxygen before moving forward.  The patient’s breathing rate and lung sounds can be very helpful in discovering the diagnosis and guiding treatment.  Lastly, circulation should be assessed.  Check the heart rate, blood pressure, peripheral pulses, skin color and temperature, and evaluate for any sites of hemorrhage.  The presence of hypotension or tachycardia should be addressed appropriately based on the presumed cause.  After the primary assessment (“ABCs”) and initial treatment actions, a more detailed history and physical exam should be conducted. 

Pertinent causes of shortness of breath for the emergency practitioner to know are outlined in the chart below. 

 

Select Causes of Shortness of Breath (Dyspnea)

Pulmonary

 

Tension pneumothorax, pneumonia, empyema, pleural effusion, pulmonary edema, asthma, COPD

Cardiovascular

 

Acute coronary syndrome (i.e., STEMI), pulmonary embolism, cardiac tamponade, Decompensated Congestive Heart Failure (acute pulmonary edema)

Endocrine

 

Diabetic ketoacidosis (Kussmaul breathing)

Toxicologic

 

Salicylate overdose, or any ingestion that causes a severe metabolic acidosis

Neurologic

 

Intracranial hemorrhage, Stroke, Spinal cord injury, Guillain-Barre syndrome, Myasthenia Gravis crisis (myasthenic crisis)

Hematologic

 

Severe anemia (i.e., GI bleeding, trauma, miscarriage, post-partum hemorrhage, ruptured ectopic pregnancy)

Musculoskeletal

 

Rib fracture, flail chest

Psychiatric

 

Anxiety, Panic attack

Airway Problem

Foreign body, epiglottitis, anaphylactic shock (laryngeal swelling), expanding neck hematoma

This patient arrives to the Emergency department with shortness of breath, productive cough, and fever for 5 days.  On exam, the patient is febrile, tachycardic, and has a low SpO2 on room air.  The lung exam demonstrates focal rhonchi at the right base.  The chest X-ray demonstrates a consolidation at the right middle lobe that obscures the right heart boarder.  The consolidation is highlighted with a red star in the patient’s X-ray below.

Lung consolidations have multiple causes, including pneumonia, malignancy, heart failure, pulmonary emboli, and septic emboli from endocarditis.  Septic pulmonary emboli (Choice A) can present with cough, fever, and difficulty breathing, but often have multiple foci of consolidations on chest X-ray.  This patient has a single area of consolidation.  This patient also lacks the typical risk factors for septic emboli, like IV drug use, recent dental procedures, structural heart disease, or prosthetic heart valves.  An infected pleural effusion (Choice B), also known as an empyema, is shown as a blunted or hazy right costo-diaphragmatic angle.  This patient’s X-ray shows no fluid in both costo-diaphragmatic recesses to indicate the presence of a pleural effusion.  A pulmonary embolism (Choice D) often presents with clear lungs on auscultation and a normal chest X-ray.  However, if the pulmonary embolism progresses to a pulmonary infarct, a wedge-shaped opacity can be seen on the X-ray.  This patient’s X-ray lacks this finding.  The most likely cause for this patient’s symptoms is a right middle lobe pneumonia (Choice C).  She should receive IV fluids, antipyretics, supplemental oxygen, and IV antibiotics.

References

Cite this article as: iEM Education Project Team, "Question Of The Day #90," in International Emergency Medicine Education Project, May 27, 2022, https://iem-student.org/2022/05/27/question-of-the-day-90/, date accessed: May 28, 2022

IFEM Medical Student Symposium – Team Gulf

Dear medical students and EM community,

We invite you to the IFEM Medical Student Symposium, the first of its kind, to discuss the present and future of undergraduate emergency medicine education. The IFEM Medical Student Symposium will bring together speakers, facilitators, and attendees from seven regions of Africa, Asia, Central and South America, Europe, the Gulf, North America, and Oceania. You can find more details on the flyer below.

It will take place on June 14th, 2022, at 13:30 AEST (GMT +10). The symposium fee is 10 AUD. Thanks to IFEM leadership and the ICEM organising committee, participants intending to join the Medical Student Symposium only can use this link on the workshop page to register without an additional conference fee.

Please share this blogpost with your colleagues and trainees who might be interested in joining this conversation. We are looking forward to meeting you all virtually at the symposium.

Best regards,
Dr Elif Dilek Cakal & Dr Erin Simon
IFEM Medical Student Symposium Co-leads
IFEM Core Curriculum and Education Committee

 

 

 

IFEM Medical Student Symposium – Team North America

Dear medical students and EM community,

We invite you to the IFEM Medical Student Symposium, the first of its kind, to discuss the present and future of undergraduate emergency medicine education. The IFEM Medical Student Symposium will bring together speakers, facilitators, and attendees from seven regions of Africa, Asia, Central and South America, Europe, the Gulf, North America, and Oceania. You can find more details on the flyer below.

It will take place on June 14th, 2022, at 13:30 AEST (GMT +10). The symposium fee is 10 AUD. Thanks to IFEM leadership and the ICEM organising committee, participants intending to join the Medical Student Symposium only can use this link on the workshop page to register without an additional conference fee.

Please share this blogpost with your colleagues and trainees who might be interested in joining this conversation. We are looking forward to meeting you all virtually at the symposium.

Best regards,
Dr Elif Dilek Cakal & Dr Erin Simon
IFEM Medical Student Symposium Co-leads
IFEM Core Curriculum and Education Committee

 

 

IFEM Medical Student Symposium – Team Central and South America

Dear medical students and EM community,

We invite you to the IFEM Medical Student Symposium, the first of its kind, to discuss the present and future of undergraduate emergency medicine education. The IFEM Medical Student Symposium will bring together speakers, facilitators, and attendees from seven regions of Africa, Asia, Central and South America, Europe, the Gulf, North America, and Oceania. You can find more details on the flyer below.

It will take place on June 14th, 2022, at 13:30 AEST (GMT +10). The symposium fee is 10 AUD. Thanks to IFEM leadership and the ICEM organising committee, participants intending to join the Medical Student Symposium only can use this link on the workshop page to register without an additional conference fee.

Please share this blogpost with your colleagues and trainees who might be interested in joining this conversation. We are looking forward to meeting you all virtually at the symposium.

Best regards,
Dr Elif Dilek Cakal & Dr Erin Simon
IFEM Medical Student Symposium Co-leads
IFEM Core Curriculum and Education Committee

 

Question Of The Day #89

question of the day

Which of the following is the most appropriate next step in management?

Shortness of breath, also known as dyspnea, is a common reason for patients to visit the Emergency Department.  Dyspnea is often caused by a pulmonary or cardiovascular condition, but it is important to remember that dyspnea can be due to endocrine conditions, toxicologic conditions, neurologic conditions, hematologic conditions, musculoskeletal conditions, and psychiatric conditions. 

The initial approach to all patients with shortness of breath involves the primary survey, or “ABCs” (Airway, Breathing, Circulation).  This first involves checking the patient for a patent airway.  A simple method to assess the airway is to ask the patient to speak and listen for the voice.  A muffled voice, the presence of stridor, hematemesis, or a lethargic patient are clues that a patent airway may not be present.  Problems with the airway, such as an obstructing foreign body, inflammation (i.e., epiglottitis, anaphylactic shock), or vocal cord dysfunction can certainly cause shortness of breath.  Endotracheal intubation may need to be performed before moving forward.  Breathing is assessed by evaluating the function of the lungs.  Steps include looking at how the patient is breathing (fast or slow), measurement of an SpO2 level, and auscultation of both lungs for wheezing, crackles, rhonchi, or distant or absent sounds.  A low oxygen level should be immediately addressed with supplemental oxygen before moving forward.  The patient’s breathing rate and lung sounds can be very helpful in discovering the diagnosis and guiding treatment.  Lastly, circulation should be assessed.  Check the heart rate, blood pressure, peripheral pulses, skin color and temperature, and evaluate for any sites of hemorrhage.  The presence of hypotension or tachycardia should be addressed appropriately based on the presumed cause.  After the primary assessment (“ABCs”) and initial treatment actions, a more detailed history and physical exam should be conducted. 

Pertinent causes of shortness of breath for the emergency practitioner to know are outlined in the chart below. 

 

Select Causes of Shortness of Breath (Dyspnea)

Pulmonary

 

Tension pneumothorax, pneumonia, empyema, pleural effusion, pulmonary edema, asthma, COPD

Cardiovascular

 

Acute coronary syndrome (i.e., STEMI), pulmonary embolism, cardiac tamponade, Decompensated Congestive Heart Failure (acute pulmonary edema)

Endocrine

 

Diabetic ketoacidosis (Kussmaul breathing)

Toxicologic

 

Salicylate overdose, or any ingestion that causes a severe metabolic acidosis

Neurologic

 

Intracranial hemorrhage, Stroke, Spinal cord injury, Guillain-Barre syndrome, Myasthenia Gravis crisis (myasthenic crisis)

Hematologic

 

Severe anemia (i.e., GI bleeding, trauma, miscarriage, post-partum hemorrhage, ruptured ectopic pregnancy)

Musculoskeletal

 

Rib fracture, flail chest

Psychiatric

 

Anxiety, Panic attack

Airway Problem

Foreign body, epiglottitis, anaphylactic shock (laryngeal swelling), expanding neck hematoma

This patient arrives to the Emergency department with acute shortness of breath, an urticarial rash, hypotension, tachycardia, swelling of the lips and tongue, and wheezing on lung exam.  This patient is in anaphylactic shock and requires prompt treatment with epinephrine.  Anaphylaxis is an IgE-mediated life-threatening allergic reaction that by definition affects two or more body systems (i.e., skin/mucosa, pulmonary, cardiovascular, gastrointestinal, etc.).  This patient has involvement of the skin (urticarial rash, mucosal swelling), cardiovascular system (hypotension and tachycardia), and pulmonary system (wheezing).  Symptoms of anaphylaxis may include urticaria, shortness of breath, wheezing, facial or airway swelling, vomiting or diarrhea, and abdominal pain.  Anaphylaxis is a clinical diagnosis and does not require vital signs to be unstable in order to be diagnosed.  Once diagnosed, the most time sensitive and lifesaving treatment is epinephrine.  The recommended initial dose for epinephrine is 0.3-0.5mg intramuscularly in the thigh for adults.  Epinephrine doses can be repeated every 5-15 minutes if there is no improvement after the initial dose. Antihistamines, like Diphenhydramine (Choice D) or famotidine may be helpful as adjunctive treatments, but they are not lifesaving.  Steroids, like Dexamethasone (Choice C), are also routinely given in anaphylaxis with the theory that they can prevent “rebound” allergic reactions.  Again, steroids are not acutely lifesaving and should be given after IM epinephrine.  IV epinephrine can be given in a patient unresponsive to IM epinephrine at a dose of 1-5mcg/min.  A dose of IV Epinephrine 1mg (1000mcg) (Choice A) is the dose of Epinephrine used during cardiac arrest and is too high of a dose to use in anaphylaxis.  The best initial step in management is IM Epinephrine 0.3mg (Choice B).  

References

Cite this article as: iEM Education Project Team, "Question Of The Day #89," in International Emergency Medicine Education Project, May 20, 2022, https://iem-student.org/2022/05/20/question-of-the-day-89/, date accessed: May 28, 2022

IFEM Medical Student Symposium – Team Europe

Dear medical students and EM community,

We invite you to the IFEM Medical Student Symposium, the first of its kind, to discuss the present and future of undergraduate emergency medicine education. The IFEM Medical Student Symposium will bring together speakers, facilitators, and attendees from seven regions of Africa, Asia, Central and South America, Europe, the Gulf, North America, and Oceania. You can find more details on the flyer below.

It will take place on June 14th, 2022, at 13:30 AEST (GMT +10). The symposium fee is 10 AUD. Thanks to IFEM leadership and the ICEM organising committee, participants intending to join the Medical Student Symposium only can use this link on the workshop page to register without an additional conference fee.

Please share this blogpost with your colleagues and trainees who might be interested in joining this conversation. We are looking forward to meeting you all virtually at the symposium.

Best regards,
Dr Elif Dilek Cakal & Dr Erin Simon
IFEM Medical Student Symposium Co-leads
IFEM Core Curriculum and Education Committee

 

IFEM Medical Student Symposium – Team Asia

Dear medical students and EM community,

We invite you to the IFEM Medical Student Symposium, the first of its kind, to discuss the present and future of undergraduate emergency medicine education. The IFEM Medical Student Symposium will bring together speakers, facilitators, and attendees from seven regions of Africa, Asia, Central and South America, Europe, the Gulf, North America, and Oceania. You can find more details on the flyer below.

It will take place on June 14th, 2022, at 13:30 AEST (GMT +10). The symposium fee is 10 AUD. Thanks to IFEM leadership and the ICEM organising committee, participants intending to join the Medical Student Symposium only can use this link on the workshop page to register without an additional conference fee.

Please share this blogpost with your colleagues and trainees who might be interested in joining this conversation. We are looking forward to meeting you all virtually at the symposium.

Best regards,
Dr Elif Dilek Cakal & Dr Erin Simon
IFEM Medical Student Symposium Co-leads
IFEM Core Curriculum and Education Committee

 

IFEM Medical Student Symposium – Team Africa

Dear medical students and EM community,

We invite you to the IFEM Medical Student Symposium, the first of its kind, to discuss the present and future of undergraduate emergency medicine education. The IFEM Medical Student Symposium will bring together speakers, facilitators, and attendees from seven regions of Africa, Asia, Central and South America, Europe, the Gulf, North America, and Oceania. You can find more details on the flyer below.

It will take place on June 14th, 2022, at 13:30 AEST (GMT +10). The symposium fee is 10 AUD. Thanks to IFEM leadership and the ICEM organising committee, participants intending to join the Medical Student Symposium only can use this link on the workshop page to register without an additional conference fee.

Please share this blogpost with your colleagues and trainees who might be interested in joining this conversation. We are looking forward to meeting you all virtually at the symposium.

Best regards,
Dr Elif Dilek Cakal & Dr Erin Simon
IFEM Medical Student Symposium Co-leads
IFEM Core Curriculum and Education Committee

Emergency Procedures: Intraosseus Needle Insertion

emergency procedures-Intraosseus Insertion

Indications

  • Emergency intravenous access is required and Peripheral intravenous access is difficult or has failed.

This video has been provided by Emergency Procedures App developers (Dr John Mackenzie and Dr James Miers) in order to help medical students, interns in training. Please visit the video source or Emergency Procedures app for more procedure videos and information. 

Contributors

Dr John Mackenzie

Dr John Mackenzie

Dr John Mackenzie MBChB , Dip MSM, FACEM . Staff Specialist Emergency Medicine, Consultant Hyperbaric Medicine Specialist, at Prince of Wales Hospital. Known for cycling endlessly for no apparent reason. 20 years of developing virtual learning for clinicians at all levels.

Dr James Miers

Dr James Miers

Dr James Miers BSc BMBS (Hons) FACEM, Staff Specialist in Emergency Medicine, Prince of Wales Hospital, Sydney. Passion for gypsy jazz and chess. Lead author of Lead author of Emergency Procedures App.

Further Reading

Emergency Procedures: Patella Relocation

emergency procedures-patella relocation

Indications

  • Patella dislocation

This video has been provided by Emergency Procedures App developers (Dr John Mackenzie and Dr James Miers) in order to help medical students, interns in training. Please visit the video source or Emergency Procedures app for more procedure videos and information. 

Contributors

Dr John Mackenzie

Dr John Mackenzie

Dr John Mackenzie MBChB , Dip MSM, FACEM . Staff Specialist Emergency Medicine, Consultant Hyperbaric Medicine Specialist, at Prince of Wales Hospital. Known for cycling endlessly for no apparent reason. 20 years of developing virtual learning for clinicians at all levels.

Dr James Miers

Dr James Miers

Dr James Miers BSc BMBS (Hons) FACEM, Staff Specialist in Emergency Medicine, Prince of Wales Hospital, Sydney. Passion for gypsy jazz and chess. Lead author of Lead author of Emergency Procedures App.

Further Reading

Emergency Procedures: Shoulder Immobilisation

emergency procedures-shoulder immobilisation

Indications

  • Shoulder dislocation (post reduction)
  • Acromioclavicular injuries (grade 1-3)
  • Fracture of humeral head, greater tuberosity or clavicle

This video has been provided by Emergency Procedures App developers (Dr John Mackenzie and Dr James Miers) in order to help medical students, interns in training. Please visit the video source or Emergency Procedures app for more procedure videos and information. 

Contributors

Dr John Mackenzie

Dr John Mackenzie

Dr John Mackenzie MBChB , Dip MSM, FACEM . Staff Specialist Emergency Medicine, Consultant Hyperbaric Medicine Specialist, at Prince of Wales Hospital. Known for cycling endlessly for no apparent reason. 20 years of developing virtual learning for clinicians at all levels.

Dr James Miers

Dr James Miers

Dr James Miers BSc BMBS (Hons) FACEM, Staff Specialist in Emergency Medicine, Prince of Wales Hospital, Sydney. Passion for gypsy jazz and chess. Lead author of Lead author of Emergency Procedures App.

Further Reading

Emergency Procedures: Finger Splint

Indications

  • Fractures of distal and middle phalanx
  • Volar plate injury
  • Post reduction of dorsal PIP dislocation
  • Mallet injury (distal phalanx extensor tendon rupture with or without avulsion fracture)

This video has been provided by Emergency Procedures App developers (Dr John Mackenzie and Dr James Miers) in order to help medical students, interns in training. Please visit the video source or Emergency Procedures app for more procedure videos and information. 

Contributors

Dr John Mackenzie

Dr John Mackenzie

Dr John Mackenzie MBChB , Dip MSM, FACEM . Staff Specialist Emergency Medicine, Consultant Hyperbaric Medicine Specialist, at Prince of Wales Hospital. Known for cycling endlessly for no apparent reason. 20 years of developing virtual learning for clinicians at all levels.

Dr James Miers

Dr James Miers

Dr James Miers BSc BMBS (Hons) FACEM, Staff Specialist in Emergency Medicine, Prince of Wales Hospital, Sydney. Passion for gypsy jazz and chess. Lead author of Lead author of Emergency Procedures App.

Further Reading