Coronary artery disease Medical Presentation

Coronary Artery Disease PowerPoint Presentation

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Published on : Sep 18, 2019 | Views : 2626 | Downloads : 16

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Slide 1-

Approach to Shortness of breath Presented by: Roshan Jha, PGY2
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Objectives You don’t have to know all the diagnoses, but you do have to evaluate threat to life Know when & how to intervene. Understand your tools. Understand your available interventions. Know when to get help
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Causes: Upper Airway dysfunction: VC palsy, laryngeal mass Foreign body aspiration Pulmonary: Asthma COPD, Emphysema Lung cancer/ endo-bronchial mass Mucous plug Pneumonia ARDS/ Non cardiogenic Pulmonary hemorrhage ILD Pulmonary embolism Pleural effusion/Pneumothorax Cardiac Pulmonary edema, Heart failure Cardiomyopathy Coronary artery disease, MI Valvular dysfunction Arrhythmia Constrictive pericarditis/Pericardial effusion Toxic/Metabolic/ Systemic Anemia Metabolic acidosis Drug overdose, CO poisoning Others: Neuromuscular disease, Stroke Ascites, Anxiety
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Signs and Symptoms: Cough, fever, voice hoarseness, difficulty swallowing, wheezing, leg swelling, chest pain. Tachypnea, increased work of breathing, accessory muscle use, agitation, altered mental status, slurred speech, anxiety, History PAST MEDICAL HISTORY: Asthma, COPD, cardiac disease, dysrhythmia, foreign body aspiration, exposure to toxins Recent upper respiratory infection symptoms Smoking, alcohol, drug abuse Indwelling catheter Recent surgery, immobilization, active cancer, contraceptive use. Recurrent fevers, night sweats and weight loss History
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Physical exam Observe: Mental status Work of breathing/ use of accessory muscles. JVP Skin color Paradoxical chest wall movements, swelling/fullness. Palpate: Tracheal position, localized chest tenderness, Pulses, Peripheral edema Auscultate: Heart sounds, murmurs, rubs. Lung for air entry, wheezing, crackles and rales. Neck for upper airway stridor
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Alarm signs RR > 30 or < 8, change in pattern. Frequent pausing while speaking Worsening mental status change Worsening cyanosis Unable to maintain saturation > 90% Hypotension Clinical deterioration despite therapy
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Workup
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Imaging CXR readily available and useful, Insufficient in few cases. Identify Pneumonia, Pulmonary edema, effusion, pneumothorax. Do your own read: the radiologist may not know what you are looking for and may rarely overlook it. CTPE if high pre test probability of PE, renal failure: V/Q scan HRCT if suspicious for ILD Cardiac imaging ECHO.
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BNP/ pro- BNP Useful marker for suggesting Heart failure. Levels > 100, sensitivity 70-80&%, >400 sensitivity: 95% Low specificity. Unreliable in Renal failure, false low in obesity. NT pro-BNP better in LV dysfunction and patients on ARNI. > 900 : cutoffs.
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ABG vs. VBG Hypoxia: ABG Hypercapnia/ketoacidosis/others: VBG
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TOOLS HFNC Can deliver 100% Fio2 at rates as high as 60 L/min. PEEP NRB mask Delivers increased Fi02 Oxygen, >60% Flow upto 15 L BIPAP NIPPV PEEP Avoid if lethargic, unable to maintain airway
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Bipap Indications: COPD exacerbation with hypercarbic acidosis: pco2>45, pH < 7.3 Cardiogenic pulmonary edema Acute hypoxemic respiratory failure Contraindications: High risk for aspiration Unable to maintain airways, encephalopathy, GCS< 10 Hemodynamic instability or unstable cardiac arrhythmia Severe Upper GI bleeding Facial trauma, suspected upper airway obstruction.
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Case scenario Mr. Jones is a 72-year-old man with no known pulmonary history admitted to the hospital with Sepsis due to cholecystitis. He received antibiotics, fluids, and narcotic analgesics. On hospital day 3, he gets out of bed to go to the bathroom and becomes “winded.” When you arrive to see him, he is sitting on the edge of his bed with his elbows on his knees, breathing at 30 breaths/min. He states he cannot catch his breath. What should you do next?
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What to do next? Vital Signs ABG Chest X-ray Consider supplemental oxygen Look for underlying pathology and treat accordingly
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X-ray read as Pulmonary edema, Atelectasis. What do you do next?
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Pulmonary edema Treatment Supplemental Oxygen Continuous cardiac monitoring, telemetry (specially looking for hypo/hyper tension) Reduce Pre-load: IV Lasix, Nitroglycerine Reduce afterload if patient is hypertensive. Diuretics Lasix Naïve: Start with 20 – 40mg IV and based on response can repeat a dose in 2 hours Lasix dependent: Give 2.5x home dose. Only use IV lasix in acute settings
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Case Scenario A 67-year-old man with known history of chronic obstructive pulmonary disease admitted for UTI. 169 called by the nurse as patient is “not being himself” and is breathing rapidly. He complains of worsening SOB and has inability to get enough oxygen. His mental status waxes and wanes and he is cyanotic around the lips and cheeks. What you would you do next?
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NeXt Steps: Vitals: BP 144/88 mmHg, HR 99, RR 28, Temp 97.6F O2 Saturation: 88% on RA Pertinent Physical Findings: General: Appears uncomfortable, labored breathing CVS: Unremarkable Chest/Resp: Mild intercostal retractions, diffuse wheezing and rhonchi bilaterally
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Initial workup ABG: pH 7.32, pCO2: 58, pO2: 86, Bicarb 30 CXR: Hyperinflation with flattened diaphragm with no acute changes Initial: Supplemental Oxygen, Bronchodilators, Systemic steroids, Antibiotics +/- Monitor for symptom resolution Recheck O2 saturation Check for change in mental status Follow-up on blood work to narrow differentials Repeat ABG if needed Escalate level of care if no improvement noted and for closer monitoring
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Logistics If overnight: Discuss with 979 and work as a team to come up with a plan Nurses will call ENIT ICU nurse who manages all ICU transfers and assess ICU Versus MAT admissions. Who to call? ICU attending between 8 AM and 11 PM GMU/ Hospitalist after 11PM If your patient gets transferred, it is a good practice to personally go to ICU /MAT with the patient and sign-out to the respective team
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Take home points. Always ask for vitals when called by nurse for SOB. Have a list of differentials on your mind based on clinical scenario while examining the patient. Look for alarming/red flag signs. Always get basic labs CBC, BMP, CXR, EKG , ABG when new onset SOB or unclear. Involve your team( senior/Attending in day, 979 in ON). Closely monitor and follow up to see how they are doing. Real life patient situations are unpredictable.
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Thank you.