Rosen & Barkin's 5-Minute Emergency Medicine Consult (612 page)

• Evaluate retractions, behavior, respiratory rate, breath sounds, and skin color.
  
• Weak cry, expiratory grunting, nasal flaring, tachypnea and tachycardia, retractions, and cyanosis in neonates
  

• Pulse oximetry
  
• Cardiac and BP monitoring
  
• EKG if suspected cardiac etiology
  

• ABG for severity and acid–base determination
  
• CBC
  
• Electrolytes, BUN/creatinine, glucose
  
• Sputum cultures, smears, and Gram stain
  
• Blood cultures for fever or sepsis
  
• B-type natriuretic peptide (BNP) for undifferentiated shortness of breath or CHF severity
  
• Venous thromboembolus test (VTE) for low-risk PE
  
• HIV
  
• Seasonal and “novel” flu testing
  
• Urinary output monitoring for CHF
  
• Toxicology screen or salicylate level if suspected
  

• CXR for:
  
  • Pneumonia
    
  • Pneumothorax
    
  • Hyperinflation
    
  • Atelectasis
    
  • CHF/pulmonary edema
    
  • Abscess/cavitary lesions/other infiltrates
    
  • Tuberculosis
    
• Ultrasound for:
  
  • Lung and rib evaluation using
    linear transducer
    
  • Pneumothorax
    
  • Hemothorax/pleural effusion
    
  • CHF
    
  • Rib fractures
    
• Echocardiography using
  phased array transducer:
  
  • Cardiac effusion/tamponade
    
  • CHF/cardiac dilatation
    
  • RV dilatation for PE
    
• Spirometry (peak expiratory flow rates) for asthma, COPD
  
• Neck CT or radiographs to assess epiglottis and soft-tissue spaces, foreign body
  
• CT angiography or ventilation/perfusion scan for pulmonary embolus
  

• Chest/neck radiograph may show foreign body or “steeple sign” in croup syndromes.
  
• Chest fluoroscopy may be used to assess inspiratory and expiratory excursions if foreign body is suspected.
  

• Fiberoptic laryngoscopy to assess epiglottis, vocal cords, and pharyngeal space
  
• Bronchoscopy for foreign body in trachea or bronchus
  
• Pulmonary artery (Swan-Ganz) catheter for severe CHF, ARDS, pulmonary edema
  

See Etiology.

TREATMENT

• Assume a position of comfort for patient.
  
• 100% oxygen:
  
  • Assisted bag-valve mask (BMV) ventilation if obtunded
    
• Airway adjunct devices (oral or nasal) to maintain patency if tolerated
  
• Intubation for severe respiratory distress
  
• Needle aspiration of suspected tension pneumothorax
  

• ABCs
  
• Ensure patent airway; BVM assist or intubate for severe distress or arrest
  
• IV fluids if hypotensive
  
• 100% oxygen by face mask:
  
  • Use cautiously in patients with severe COPD or chronic CO
    ₂
    retention.
    
• Monitor BP, heart rate, respirations, pulse oximetry
  
• Advanced cardiac life support for dysrhythmias or arrest
  

• Treat underlying etiology as appropriate.
  
• CHF or pulmonary edema:
  
  • Diuretics
    
  • Nitroglycerin
    
  • Nitroprusside if hypertensive
    
  • Pulmonary artery catheter if severe
    
  • Noninvasive positive-pressure ventilation (NPPV/BiPAP) or intubation if severe
    
• Asthma, bronchiolitis, COPD:
  
  • Bronchodilators
    
  • Steroids
    
  • Antibiotics for infection
    
  • Antivirals for influenza
    
  • NPPV or intubation if severe
    
• ARDS, aspiration, toxic lung injury:
  
  • Mechanical ventilation as needed
    
  • Steroids controversial
    
• Pneumonia:
  
  • Antibiotics
    
  • Respiratory isolation for TB
    
• Pneumothorax:
  
  • Immediate decompression if suspected tension pneumothorax
    
  • Aspiration or tube thoracostomy (see Pneumothorax)
    
• Pleural effusion:
  
  • Determine etiology
    
  • Diagnostic and symptomatic thoracentesis
    
• Croup:
  
  • Cool, misted air or oxygen
    
  • Steroids
    
  • Racemic epinephrine
    
  • Antibiotics for bacterial infection
    
• Epiglottitis:
  
  • Immediate airway stabilization with intubation or tracheostomy in OR if possible
    
  • Antibiotics for
    Haemophilus influenzae
    
• Anaphylaxis, angioedema:
  
  • IV steroids
    
  • H
    ₁
    /H
    ₂
    -blockers
    
  • SQ or IV epinephrine
    
  • Early intubation
    
• Retropharyngeal abscess:
  
  • Drainage
    
  • IV antibiotics
    
  • ENT consult
    
• Cardiac:
  
  • Treat dysrhythmias or ischemia
    
  • Anticoagulation or thrombolysis for PE
    
  • Pericardiocentesis for tamponade
    
  • NSAIDs or aspirin for pericarditis
    
• Neuromuscular:
  
  • Support ventilation
    
  • Pyridostigmine bromide or neostigmine for myasthenia gravis
    
• Metabolic/toxic:
  
  • Treat underlying cause
    
• Psychogenic:
  
  • Anxiolytics
    

• Transtracheal jet ventilation if unable to intubate (cricothyrotomy not recommended in children <10 yr)
  
• Bronchiolitis:
  
  • Bronchodilators
    
  • Antivirals for respiratory syncytial virus
    
  • Antibiotics for infection
    
• Spasmodic croup:
  
  • Very sensitive to misted air
    
• Bacterial croup (membranous laryngotracheobronchitis):
  
  • Treat
    Staphylococcus aureus.
    

• Supportive oxygen therapy and heparin for PE or amniotic fluid embolism
  
• IV antibiotics for septic embolism
  

Refer to specific etiologies

FOLLOW-UP

• Continued supplemental oxygen requirement
  
• Cardiac or hemodynamic instability:
  
  • Requiring IV therapy or hydration
    
  • Requiring close airway observation or repeated treatments
    
  • Respiratory isolation
    
• As required by underlying cause or significant comorbid disease
  

• Correction of underlying disease
  
• Stable airway
  
• Acute supplemental oxygen not required
  

Refer to specific etiologies

• Consider immune-compromised state.
  
• Consider “novel” flu strains (H1N1).
  
• Start antibiotic treatment within 6 hr of ED arrival (JCAHO Quality Measure).
  

• Ausiello D, Goldman L, eds.
  Cecil Textbook of Medicine
  . 22nd ed. Philadelphia, PA: WB Saunders; 2004:492–583, 1523–1524.
  
• Barton ED, Collings J, DeBlieux PMC, et al., eds.
  Emergency Medicine: Clinical Essentials
  . 2nd ed. Philadelphia, PA: Elsevier Saunders; 2009:43–49, 173, 398, 414–434, 476–486, 1351–1368.
  
• Sigillito RJ, DeBlieux PM. Evaluation and initial management of the patient in respiratory distress.
  Emerg Med Clin North Am
  . 2003;21(2):239–258.
  
• Williams SA, Hutson HR, Speals HL. Dyspnea. In:
  Emergency Medicine: Concepts and Clinical Practice
  . 4th ed. St. Louis, MO: Mosby; 1998:1460–1469.
  

CODES

• 786.00 Respiratory abnormality, unspecified
  
• 786.05 Shortness of breath
  
• 786.09 Other respiratory abnormalities
  

BASICS

• Annually, almost 1 million deaths worldwide are related to birth asphyxia.
  
• 10% of newborns require some assistance at birth.
  
• 1% of newborns require extensive resuscitation.
  
• Consider NOT initiating resuscitation if:
  
  • Newborns confirmed to be <23-wk gestation or 400 g
    
  • Anencephaly
    
  • Babies with confirmed trisomy 13 or 18
    
  • Ideally, discuss with family and health care team prior to delivery.
    
• Activity, pulse, grimace, appearance, respiration (APGAR) scores do not guide resuscitation:
  
  • Do not wait to assign APGAR scores before starting resuscitation.
    
  • APGAR scores should NOT guide resuscitative efforts. It is a measure of an infant’s status and response to resuscitation.
    
  • APGAR score: 5 categories with score of 0, 1, or 2 in each at 1 and 5 min
    
• Heart rate (HR): 0 = absent; 1 = <100 bpm; 2 = >100 bpm
  
• Respirations: 0 = absent; 1 = slow, irregular; 2 = good, crying
  
• Muscle tone: 0 = limp; 1 = some flexion; 2 = active motion
  
• Reflex irritability: 0 = no response; 1 = grimace; 2 = cough, sneeze, cry
  
• Color: 0 = blue or pale; 1 = pink body and blue extremities; 2 = all pink