SOB
A Complaint With Many Faces
Presented by :
Dr. Chris Lee - PGY 2 ER
Dr. Matthew Davis - Staff ER Physician,
Interim Medical Director for Education
Shortness of Breath
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Objectives
Upon completion of this presentation, the
paramedic should be able to:
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Describe comprehensive pre-hospital differential
diagnoses of SOB,
Distinguish between the common causes of SOB, and
Apply pre-hospital SOB treatments to various patient
care scenarios according to the Advanced Life Care
Patient Care Standards.
Outline
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Outline common pitfalls when assessing SOB
Develop a structured approach to SOB in the
pre-hospital setting
Review protocols available to treat SOB
Case 1
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76 y/o F
Hx of angina, COPD, MI with stent, DM Type 2
Has been getting progressively SOB since the
holidays started
Has trouble lying down, sleeps in a recliner, SOB
always worse at night
Still smokes 1/2 pack per day, puffers don’t help
T: 36.8, HR: 98, BP: 104/78, RR: 24, O2: 91%
Auscultation: wheezes bilaterally
*Wheezes = COPD*
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Case 2
81 y/o M
• Hx of HTN, CAD, dyslipidemia, MI, stroke 6
months ago with speech/swallowing deficits
• Acutely SOB while eating dinner
• Has some pain with respirations, took nitro
without any benefit
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T: 37.0, HR: 92, BP: 147/93, RR: 20, O2: 94%
Auscultation: crackles at bases
*Crackles = CHF*
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Case 3
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9 y/o M
SOB for the past day or so
Has been feeling generally unwell for a couple
days, worst today, feels increasingly SOB
Parents called because very fatigued, N/V,
confused, complains of thirst
Looks dehydrated, drowsy, hyperpneic
T: 37.6, HR: 128, BP: 102/66, RR: 34, O2: 99%
Auscultation: Normal breath sounds
*Many causes of SOB*
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Shortness of Breath
Dyspnea
Sensation of breathlessness and the patient’s
reaction to that sensation.1
Imbalance of the perceived need to breathe,
and the perceived ability to breathe.2
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O2 in
Carotid Bodies
Thoracic Cage
Protection, inhalation,
stretch receptors
Diaphragm
Inhalation
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Negative pressure
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O2 in
Carotid Bodies
CO2 out
Medulla Oblongata
Trachea
Conduit, vocal structures
Lungs
Gas exchange
Thoracic Cage
Protection, inhalation,
stretch receptors
Heart
Pump
Diaphragm
Inhalation
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Foreign body
Supraglottitis
Vocal Cord Paralysis
Croup
Trauma
Anaphylaxis
Trachea
Rib Fractures
Flail Chest
Thoracic Cage
Metabolic
DKA
Renal Failure
Electrolyte abnormalities
Metabolic Acidosis
Thyroid disease
Obesity
Pregnancy
Ascites
Intraabdominal
infection/sepsis
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Abdomen
Pulmonary Embolus
Pneumothorax
Asthma
Aspiration
Pneumonia
Pleural Effusion
Neoplasm
COPD
Inhalation injury
ARDS
Pulmonary Contusion
Lungs
Heart
Pulmonary Edema
Myocardial Infarction
Cardiac Tamponade
Pericarditis
Valvular Disease
Cardiomyopathies
Dysrhythmia
Diaphragm
Ruptured Diaphragm
Hiatus Hernia
Diaphragm paralysis
Hematologic
CO Poisoning
Acute Chest Syndrome
Anemia
Treatable (pre-hospital) causes of
dyspnea
Trachea
Foreign Body
• Croup
• Anaphylaxis
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Lungs
Pneumothorax
• Asthma
• COPD
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Heart
Cardiogenic Pulmonary Edema
• Cardiac Ischemia/Myocardial Infarction
• Dysrhythmia
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Trachea
Foreign Body
Child: not watched,
missing objects
Adult: while eating,
taking pills
Stridor,
• audible wheeze,
• coughing,
• vomiting,
• possible
decreased BS
*Stridor*
*High risk story*
Croup
Children, late
fall/winter,
• 6 mo - 6 yrs,
• Viral illness
prodrome
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•
Seal-bark cough,
hoarse voice,
stridor
*Stridor*
*Seal-bark cough*
Anaphylaxis
History of allergy,
• GI,
• Skin complaints,
• Possible exposure
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Angioedema,
• Urticaria,
• N/V,
• Possible shock,
• Wheezing,
• Cough, stridor
*High-risk story*
*Cluster of symptoms*
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Trachea
Foreign Body
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BLS maneuvers if
awake
If arrested, can
attempt removal
If arrested after
removal, run
medical cardiac
arrest
Croup
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If severe respiratory
distress:
Nebulized epinephrine
Anaphylaxis
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IM epinephrine
IV/IM
diphenhydramine
Lungs
Pneumothorax
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Blunt or penetrating
thoracic trauma
Spontaneous in tall,
young men, also COPD
Tension: accumulating
air, compression of
mediastinum
Usually acute onset
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Chest pain, decreased
BS unilaterally
*Tension* ++ acutely ill,
cyanotic, hypotensive
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*Acute, high risk story*
*decreased BS
unilaterally*
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Asthma
COPD
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History of atopy,
• Puffer use,
• Worse at night,
Triggers: allergens,
exercise, stress
Cough,
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WOB, Air entry
• Diaphoresis,
• Wheezing
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*High-risk story*
*wheeze*
Long pre-morbid
course,
• Smoking,
• SOBOE,
• Chronic cough
Cough,
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WOB, Air entry
• Wheezing, crackles
• Auto-PEEP, unwell
appearance
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*High-risk story*
*wheeze*
Lungs
Pneumothorax
Asthma
COPD
If tension:
Needle thoracostomy
*NO* CPAP
CPAP
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MDI/Nebulized
Ventolin
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MDI/Nebulized
Ventolin
Heart
Pulmonary Edema
(Cardiogenic)
MANY causes:
Infarction,
cardiomyopathies,
valvular dysfunction,
dysrhythmia, volume
overload, …)
Hx of:
Heart issues,
orthopnea, PND, SOBOE
Often worse at night
Auscultation:
Crackles, wheezes,
extra heart sounds, if
R-sided failure: JVP,
leg edema
*High-risk story*
*Crackles bilaterally*
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Dysrhythmia
Brady
Hx of
conduction
problems
Tachy
Hx of similar
episodes
SOB, syncope
SOB,
Palpitations
EKG changes
(SSS, AV
blocks, …)
EKG changes
(A.Fib/Flutter
, AVNRT, …)
*EKG*
*EKG*
Cardiac Ischemia
Chest pain,
associated SOB,
worse with exertion
History of angina,
nitro
CVS and Resp N, may
have extra heart
sounds
EKG changes
possible
*High-risk story*
*EKG*
Heart
Pulmonary Edema
(Cardiogenic)
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SL Nitroglycerin
If in setting of
STEMI and shock:
• IV Saline
• IV Dopamine
Dysrhythmia
Brady
Tachy
Cardiac Ischemia
PO ASA
• SL Nitroglycerin
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If unstable:
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Atropine
BHP
guidance:
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Transcut.
Pacing
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Dopamine
AVNRT/AVRT
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Valsalva
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Adenosine
BHP
guidance:
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Widecomplex
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Amiodaro
ne
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Lidocaine
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Cardiovers
ion
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IV Morphine
If in setting of
STEMI and shock:
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IV Saline
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IV Dopamine
History, History, History
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Start with history
Start with protocols
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Case 4
68 y/o M
• Hx of COPD, CABGx3, anxiety, HTN, DM2
• Cough, SOB x 2 weeks, now spiking fever
• Greenish sputum, wife calls because now
confused, GP 5 days ago put him on unknown
antibiotic
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T: 38.6, HR: 117, BP: 96/74, RR: 25, O2: 89%
Auscultation: crackles and air entry RLL,
wheezes B/L
*Multiple diagnoses can coexist*
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Questions?
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References
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1.
Marx JA, Hockberger RS, Walls RM, Adams JG,
Barsan WG, Biros MH, et al., editors. Rosen’s
Emergency Medicine: Concepts and Clinical
Practice. 7th ed. Philadelphia: Mosby Elsevier; 2010
2.
Rawy A. Dyspnea [internet]. [Update Jul 2008, Cited
Mar 2013] Available online from:
http://www.slideshare.net/cairo1957/dyspnea