00:00
So when someone comes in in respiratory distress, the examination, you want to look at the
patient. You can gather so much information just by looking at the patient from the door. You
want to listen, you want to take a listen to your lungs. That can give you a clue as to what's
going on with the patient. If you hear wheezing, that's potentially obstructive lung disease
or asthma. If you hear rales or crackles, that's more likely to be CHF. And you want to go
ahead and feel the patient's chest. You can do tactile fremitus and egophony. And the key
thing in patients with respiratory distress is you're going to be treating them and examining
them potentially all at the same time. So when someone comes in with severe respiratory
distress, oftentimes our treatment and our exam and our history are all taking place at the
same time because we're moving very quickly to rapidly treat and assess the patient. Now a
key thing with respiratory distress is you always want to be reassessing your patient so you
always want to be going back to your patient after you've given them a certain treatment,
after you've given them nebulizer treatments or diuretics or started them on non-invasive
ventilation and you always want to be going back and reassessing your patient. Your further
physical exam, we want to focus on the respiratory rate. Oftentimes when someone is having
significant respiratory distress, the respiratory rate will be elevated though sometimes you
want to go ahead and you want to make sure you're focusing on that and that you're counting
the respiratory rate and seeing what it is. Oftentimes, it will be obvious that the patient's
respiratory rate is elevated. You want your patient to be on a pulse oximeter. You want to be
able to measure their oxygen saturation and generally peripheral pulse oximeters are non
invasive pulse oximeters do a pretty good job of measuring the patient's oxygenation. You
also want to think about the patient's position. So oftentimes our instincts are for people
to be lying flat in bed or flat on the stretcher, but for the most part if someone's in severe
respiratory distress you want to sit them up in bed and the reason that you want to sit them
up in bed is because when you're sitting up you're able to take deeper inhalations and you're
able to recruit more of your lung volume. When you're lying down flat, you're not able to do
that. The other thing that happens when you sit people up especially if they have some fluid
in their lungs is the fluid goes to the bottom of their lungs and then they're able to utilize again
larger portions of their lung volume and they're able to fill their lungs with more fluid. So
gravity is your friend. Go ahead and sit those patients up. The fluid will go down, they're
going to be able to breathe better in that situation. Lastly is listening and you want to
definitely take a listen to the lungs, you want to see if you hear wheezes, if you hear crackles,
if you hear crackles how far up those go, rhonchi or the other thing that you can sometimes
hear, and all of those things will point you in a direction as to what you think is the most likely
etiology of the shortness of breath for a patient. So in respiratory distress, the physical exam
can provide you with lots of clues to the etiology of our patient's shortness of breath. Go
ahead and utilize that exam, and much of that important information on the physical exam can
actually be gathered in the first few seconds simply by walking in the room and looking at
your patient. Looking at your patient, you could see if they're in respiratory distress. You
can touch them very quickly and see if they're cool and clammy or if they're warm and red.
03:40
Also there's lots of information that you can just get in those first few seconds. Make sure
that you utilize those first few moments to take a look at your patient. So like I said, in these
situations we're going to be doing lots of step at the same time. We're going to be examining
our patient, we're going to be intervening on their shortness of breath, we're going to be
reassessing them, and then we're also going to be thinking about what initial tests we want to
get. So we're going to start up by talking about some blood tests that you're going to
want to get. When thinking about shortness of breath, we want to focus on the blood gas.
04:14
And when we're talking about a blood gas. For the most part in the emergency department,
we utilize venous blood gases. Historically, we used to get arterial blood gasses. So we used
to take blood from the artery and send that to the lab to analyze it. The advantage of taking
an arterial blood gas over a venous blood gas is that an arterial gas can help you further
assess the oxygenation. But like I said for the most part, our peripheral pulse oximeters that
go on the patient's finger do a pretty good job of assessing the oxygenation. So for the most
part in the ED, we sent a venous blood gas and the venous blood gas can take a pretty good
look at the ventilation. So when we're talking about ventilation, we're talking about whether
or not that person is able to adequately expire their carbon dioxide and when we're looking
at a venous blood gas and our arterial blood gas they actually correlate pretty closely
together. The other problem with an arterial blood gas is that can be challenging to get. For
the most part, arterial blood gasses were obtained from the radial artery, which is the artery
in the wrist. Now that historically can be painful for patients so we know that patients report
a lot of pain with that procedure so generally we do the venous blood gas instead and we
can just send the venous blood gas off with the rest of the labs that are sent off. We want to
think about cardiac testing. So shortness of breath is sometimes due to problems in the lungs,
but sometimes it's due to a problem with the heart so we want to think about sending off
troponin testing. And then, other basic lab tests can give you additional information as well.
05:46
So, thinking about basic blood tests, you can find out if the patient is anemic. This anemia can
cause shortness of breath. You can find out if there is kidney failure. The next step is thinking
about imaging. So in imaging, we think about getting a chest x-ray. The chest x-ray can give
you lots of information. It can take a look at the lung fields, you could see if there is a
pneumonia and pneumothorax, if there's fluid in the lungs, and it can give you a lot of
information about what's going inside the patient's lungs. However, additionally, if your chest
x-ray is potentially not very revealing or you're not sure, you can move on and you can get a
chest CT after you get some additional information. A chest CT scan gives you the advantage
of taking a closer look at the patient's lung fields. The other thing that it can do is if you
administer IV contrast with a chest CT, you can take a look at the vessels in the lungs and see
if there's a blood clot there. An ultrasound scan of the lung can also be used in emergency
settings to evaluate the pulmonary pleura and parenchyma. It can show signs of pleural
effusion, consolidation, interstitial disease, and pneumothorax among other conditions. The
lung ultrasound scan has additional advantages over chest x-rays and CT scans due to its
availability, portability, absence of radiation, and real time application. Lastly, thinking about
additional cardiac testing, the EKG is something that you can get that will look for ischemia.
07:16
So you can look and you could see if there is any evidence that the patient is having a heart
attack or a myocardial infarction. You can also look for arrhythmias. Arrhythmia sometimes
also can make people feel short of breath such as atrial fibrillation or atrial flutter, and then
an echocardiogram. In the emergency department, we utilize bedside point of care ultrasound
quite a lot and an echocardiogram is something that can be obtained easily and quickly.
07:41
Studies have shown that in the emergency department, emergency medicine physicians are
good at figuring out if the patient has a good EF, a medium EF, or a low EF. So we're good at
kind of approximating that and as technology just keeps getting better and where you are
training our residents I think that this scale will only get utilized more and more over the
upcoming years.