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FACP. Colegio de médicos de Tarragona Nº 4305520 / fgcapriles@gmail.com




Saturday, February 27, 2016

Shortness of Breath in the ED

Taming The SRU - February 26, 2016 - By Jon Mckean
"There are many chief complaints in the emergency department that can be less than satisfying (*cough* abdominal pain *cough*). Sometimes such patients end up having a completely benign examination, no significant risk factors found on history, and an encounter that leaves you shrugging your shoulders and telling the patient “bellies will do that sometimes, we don’t always find out why.”
Of course, this is all anecdotal, but the chief complaint on this month’s episode seems to have a more consistent presence of pathology with a wide range of severity. With such heterogeneous pathophysiology we turn to the mind of Dr. Stewart Wright to discuss the initial approach to the patient with shortness of breath (SOB). 
Some highlights from his episode include:
  • Perhaps the most important part of your physical exam is your view of the patient from across the room. Take a moment to really watch how the patient is breathing, what rate, with what degree of effort, etc.
  • Adopt the A-B-C approach when assessing shortness of breath to prioritize immediate life threats. Assess for airway compromise first, if not present, move on to breathing and circulation as potential causes for SOB.
  • Utilize past medical history and chart review to help guide your differential, but be careful not to succumb to anchoring
  • Early review of vitals is key, including a true respiratory rate and SpO2. Begin oxygen therapy during your assessment if it is indicated, start big and wean down once you reach a safe oxygenation status. 
  • (And if I may add my own suggestion, again anecdotal, adopt early use of ultrasound in your assessment. In addition to looking for pneumothorax, pulmonary edema and cardiac contractility, I have been lucky to stumble upon several unexpected pericardial effusions when my exam hadn’t revealed any cardiopulmonary findings.)"