Hi, we're gonna be talking about how to approach respiratory distress
in the emergency department.
So, whenever we think about respiratory distress,
we're thinking about a patient who comes into the emergency department,
who's having a very hard time breathing.
So, when we're thinking about someone who is critically ill
and is having a hard time breathing,
we wanna make sure we go back to the basics
and the basics in the emergency department, we go back to our –“
at the beginning of our alphabet and we think about the ABC's.
When we–re talking about the ABC's, first, we're gonna start with the airway.
So, when thinking about the airway, we want to say is the airway patent?
Does the patient have anything occluding their airway?
Do they have a lot of swelling in their airway?
And an easy way for us to do that is to ask the patient to speak.
So, generally, patients who are able to speak have a patent airway.
The other thing we think about is, is the airway –“
is the patient able to protect their airway?
So, what does that mean?
That means that if the patient were to vomit or have a lot of secretions,
would they be able to handle those secretions?
The next thing we think about is breathing
and we wanna make sure we're assessing the work of breathing for our patient.
This is something that can be done using a couple of parameters.
So, one of the first things we want to do is assess the pulse oximetry.
So, we want to see if the patient has hypoxia? Is their oxygenation okay?
And the other thing that we can do when we're thinking about this
is just looking at our patient and talking to our patient.
So, when looking at the patient, are they using accessory muscles?
Is their respiratory rate elevated?
Do you see them using their sternocleidomastoids to help them breathe?
Are they using their abdominal muscles to help them breathe?
And along with this, it's also talking to your patient like I said.
So, can your patient speak?
In order to speak, you need to be able to breathe.
So, patients who come in who are screaming at the top of their lungs
and saying they're having a hard time breathing, most likely,
they're not necessarily having as much of a hard time breathing.
So, you wanna see are they able to speak one word sentences,
are they able to speak longer paragraphs and longer sentences along the way.
And then circulation is the last part of this here.
So, you wanna check the blood pressure,
you wanna check peripheral pulses in the extremities,
and along with this, you want to feel is the patient's skin cool?
Is their skin warm? Are they clammy?
All of that kind of goes into the circulation component.
So, before we can move on to anything else,
we wanna make sure we're starting with our ABC's.
If we detect a problem in any of these components,
if we detect a problem with airway, with breathing, with circulation,
we always say we have to stop and fix that problem before we can move on.
So, if we detect an airway problem, we stop at A,
we fix it with potentially intubation, and then we don't move on
until we've fixed all of the problems here before we move on to the rest of our process.
So, when someone comes in with respiratory distress,
we wanna think about the most important questions you have to ask and sometimes,
you have to ask and think about these things pretty rapidly.
This is something where we're not gonna wanna take your time.
Your patient is having respiratory distress.
They're having a hard time breathing.
You don't wanna just kind of, wait around.
So, the important questions that you wanna be thinking about,
that you wanna be asking right when you see this patient.
So, you wanna know when did it start?
Did it start just before they came in?
Did it start five days ago? Did it start months ago?
Is this a chronic problem for the patient?
Did the symptoms begin suddenly or where they more of gradual onset?
So, sudden onset of shortness of breath makes you think about certain things.
More gradual onset of shortness of breath makes you think about other potential etiologies.
Has this ever happened before?
There are a lot of things that cause respiratory distress that have happened before for patients.
So, for example, COPD, asthma, those are generally recurrent problems
for patients who get intermittent exacerbations or something
like a pulmonary embolus might be something that just happens one time for a patient.
Are there any other associated symptoms?
For example, is your patient having chest pain?
Have they had leg swelling? And any other kind of associated symptom they can have.
Are they having a fever? Are they having a cough?
There's lots of other things that you wanna make sure that you're asking about.
And then past medical history. What other medical problems does the patient have?
Do they have obstructive lung disease? Are they a smoker?
Have they had heart attacks before? Do they have heart failure?
Are they on diuretic medication?
So, all of that stuff, you wanna try and formulate as quickly as you possibly can.
The history can provide you with lots of clues as to the idealogy of a patient's shortness of breath.
So, it's important to try and gather as much information as possible.
And not just gathering as much information as possible,
but to try and gather this information as quickly as you possibly can.
Now, the main issue here when we're dealing with respiratory distress,
especially for those patients that are severely dyspneic,
so for patients who are really struggling to breathe and talk.
So, for example, that patient that can only speak a couple of words at a time,
they're not gonna be able to tell you all of their medical history or when it started necessarily.
So, for those patients, what you're gonna need to do is you're gonna need to utilize other resources.
You're gonna need to reach out to the EMTs who brought the patient in to the emergency department.
So, the family potentially or friends who've been with the person over the last little bit.
So, the medical record can sometimes be very helpful to help obtain historical information.
So, you may be in a situation where you're not necessarily able to ask your patient all of these questions.
Now, this may be different than other clinical experiences that you've had in the past.
Often times, in the pre-clinical years of medical school, if you have some patient contact,
usually, that's gonna be with a stable patient.
Here, these patients are gonna be very sick potentially and you're gonna wanna try
and gather as much information as quickly as you can,
and potentially utilize these additional resources.