shortness of breath/ chest pain

[Kiwiology]

I forgot heart failure can produce a wheeze that sounds like asthma ....perhaps its not so simple after all!

[HERBIE1]

Holy crap, never realized how much I've come to depend on ECG until now. I won't worry too much about it though, plenty of non-STEMI's out there.

I know this was a college scenario so we're working on a piece of fiction here, but I'd be curious about initial HR, RR and BP. On all my SOB calls I've gotten in the habit of adding ETCO2 into the mix to take a look at the waveform.

Dive back into the Hx. Some people have a weird perception of pain. Yes the crushing CP occurred following ventolin administration, but did anything feel out of the ordinary in the chest prior to that?

How did the lungs sound after the initial ventolin treatment? Were I to hear increased wheezes or crackles then I'd start considering CHF.

Given his history, I am inclined to lean more towards cardiac ischemia brought on by the asthma and ventolin treatment.

Of course this is where it gets a bit stickier. Has the Pt. ever had asthma complications with ASA usage? Under my Medical Directive NTG is contraindicated when the Pt. has no prior NTG use w/o a line established.

I can tell why this one was used in school for you. Forces the student to make a decision and operate in that grey area where so many Pt.'s fall.

Our NTG protocol is BP related. Anything over 100/P is OK. I understand it is theoretically possible for Ventolin to induce chest pain, but in the thousands of chest pain cases where a person also has asthma, I have never seen it. To me, I'd be pursuing the cardiac ischemia aspect of this. O2, NTG, ASA, etc.

Too often, Chest pain. MI symptoms are atypical: only SOB, only a general malaise, only "heart burn"(in my case), only nausea, etc. You need to do a complete history- precipitating factors, onset of symptoms, vitals, etc, and I think they will point you in the direction you need to follow.

I agree with you on these grey areas being very important. Anyone can be a cookbook medic, but often it takes some experience, assessment skills, and detective work to dig a bit deeper to get to the truth.

[rock_shoes]

So, interesting scenario. Now that everyone seems to agree the pathology is not as simple as initial impressions why don't we push this exercise a step further and state our treatment plans based on the information available. Including the reasoning behind your chosen plan of action of course.

[kohlerrf]

Okay, going out on a limb here folks as I am new to the forum and still fairly new to the world of EMS. If you are treating a patient that is having SOB with the Ventolin protocol and while giving them the first dose of Ventoline they develop chest pain. What would one do? Now the pt. states they do have Asthma, but also have suffered two episodes of Angina within the last two years and are prescribed NItro.

Should one stop the treatment of Ventolin, apply high flow O2 and then start down the Chest Pain protocol or do you continue with the SOB protocol while questioning the the pt. about the chest pain they suddenly developed?

I guess my thinking is yes, they have a cardiac hx, but at the same time they have Asthma and said they have been exposed to lets say dust which brings on their Asthma and are having a hard time breathing and used their puffer that did not help. I feel I should continue with the Ventolin protocol and question my patient about the chest pain they are experiencing.

Any comments good or bad are welcome!

Sorry if my questions seems a little confusing. If you need any more clarification feel free to ask me.

All that wheezes is not asthma! I don't know enough about your exam of the patient and if you ruled out an MI or how well your patent was ventilating them selves Pusiox, ETCO2,pulse and resp rate (think IPI). In addition I believe Ventolin has a Beta 1 component that we would want to stay away from in the face of an MI. you would have to rule out the MI or pulmonary edema causing angina/MI before making any treatment choices. Remember if you your pulsox is greater than 95% and your ETCO2 is say 40 and your rate 10 to 20 you have time to look other places for the cause of the wheeze or difficulty in breathing. Never go down the cook book protocol page of SOB remember to step back look at you patient and use all your tools to figure out what is going on before you treat.

[zippyRN]

a lot of the key factors are emerging

what does the 12 lead say , is this actually asthma or is it 'cardiac asthma' as a symptom of failure

is the patient beta blocked ? and what does that mean if you want to give him Salbutamol ( Ventolin is a trade name).

high flow ? or high FiO2 ?

[EMT155]

Great conversation gong here....

On the Vol side, I work as a BLS, non transporting first responder, no ECG or invasive techniques. In that situation, if the CP started prior to the initiation of the ventolin/albuterol Tx, I would be starting ALS on a priority. Continue the Albuterol (just for clarification as it's how our protocols are written) Tx using a NRM attached to the neb. I would also give the pt a chewable baby aspirin and assist taking a NTG as long as the Systolic is greater than 90. At this point, I'm monitoring v/s and updating the ALS awaiting their arrival. We don't have any contraindications for albuterol based on cardiac issues here, so that doesn't play in here.

At work, I am the BLS half of the crew, and would assist the ALS provider with starting the albuterol, getting a pulse ox, ECG and then possibly NTG and aspirin as per protocols. Good chance I would also be setting up a line for them to initiate IV access and getting to the ED at a decent pace.

HOWEVER.......

If I had any suspicion of CHF (ie: lung sounds a little on the 'bubbly' side), I may be more inclined to bypass the albuterol and go straight for O2 via NRM @ 15lpm+ and assist with NTG and advise ALS to expedite. at work.... That's what the paramedics are for

Jim

[PCP]

After reading all the posts, it seems as though I best be doing some more reading, and try to understand more on how SOB can be caused by chest pain and vis versa. As stated before, we do not have ALS available in our community, so I best learn and understand the complications of someone having SOB along with chest pain.

Over the weekend I was called out for a lady with SOB, and we arrived and the lady did not look as though she was having any problems breathing, and was outside waiting for us. When we pulled up she walked over to the ambulance and just said that she had taken her puffers that day and they did not seem to help her. I had her get into the ambulance where I got my hx from her and she was very calm, and just stated that she has been short of Breath all day, and that she has some chest pain as well.( Hmmm I thought to myself I just posted a question on this exact scenario what are the chances eh!)

The end result was I decided to give her Ventolin and transport her to the hospital based on her signs and symptoms from the questioning I did I felt her chest pain was because of her taking her puffer 4 times that day, and that the B1 effects had caused the chest pain. Later that night, I was back at the hospital with another pt. (Another story for later. It was a good One!!)

I spoke to the Dr. and he stated that "Yes she was having a mild Asthma attack, and that her EKG was normal, and the chest pain was due to the effects of her taking her Ventolin." I felt good as that was my first SOB call as a licensed PCP and my first shift at my new station

Now that does not mean I am going to treat every SOB call with chest pain as though the chest pain is being caused by the B1 effects of Ventolin, as I know that this is not allows going to be the case. One thing I learned from this call over the weekend is that, pt. do not present the same as they did in class with the classic signs and symptoms when they are experiencing SOB. My pt. was talking in full sentences, was not using any excessory muscles to breath, had good skin color, SPO2 reading was good, and when I auscultated her lung sounds they sounded clear. ( But I am still learning how to diagnose the different lung sounds, so maybe I thought she had clear lung sounds, when the matter of fact she did have some mild wheezes.

All and all, it was a good call and I got her to the hospital where she could be taken care of and was able to go home a few hours later.

[HERBIE1]

After reading all the posts, it seems as though I best be doing some more reading, and try to understand more on how SOB can be caused by chest pain and vis versa. As stated before, we do not have ALS available in our community, so I best learn and understand the complications of someone having SOB along with chest pain.

Over the weekend I was called out for a lady with SOB, and we arrived and the lady did not look as though she was having any problems breathing, and was outside waiting for us. When we pulled up she walked over to the ambulance and just said that she had taken her puffers that day and they did not seem to help her. I had her get into the ambulance where I got my hx from her and she was very calm, and just stated that she has been short of Breath all day, and that she has some chest pain as well.( Hmmm I thought to myself I just posted a question on this exact scenario what are the chances eh!)

The end result was I decided to give her Ventolin and transport her to the hospital based on her signs and symptoms from the questioning I did I felt her chest pain was because of her taking her puffer 4 times that day, and that the B1 effects had caused the chest pain. Later that night, I was back at the hospital with another pt. (Another story for later. It was a good One!!)

I spoke to the Dr. and he stated that "Yes she was having a mild Asthma attack, and that her EKG was normal, and the chest pain was due to the effects of her taking her Ventolin." I felt good as that was my first SOB call as a licensed PCP and my first shift at my new station

Now that does not mean I am going to treat every SOB call with chest pain as though the chest pain is being caused by the B1 effects of Ventolin, as I know that this is not allows going to be the case. One thing I learned from this call over the weekend is that, pt. do not present the same as they did in class with the classic signs and symptoms when they are experiencing SOB. My pt. was talking in full sentences, was not using any excessory muscles to breath, had good skin color, SPO2 reading was good, and when I auscultated her lung sounds they sounded clear. ( But I am still learning how to diagnose the different lung sounds, so maybe I thought she had clear lung sounds, when the matter of fact she did have some mild wheezes.

All and all, it was a good call and I got her to the hospital where she could be taken care of and was able to go home a few hours later.

A couple take home points here-

Since you are BLS, I understand you are limited in the tools you have available. That said, it makes a good set of vitals massively important. The most important thing you need to do is ensure you have a solid baseline to work from- good solid vitals. As you noted, lung sounds are difficult to master, but the only thing you can do is keep at it. I cannot tell you how many times I've picked up fine rales in the bases of someone's lungs, even with no obvious respiratory distress. As you probably know, someone with CHF can QUICKLY decompensate. Minor distress can progress to full blown pulmonary edema and sometimes it can be hard to mitigate the problem. Thus, it's imperative to be able to distinguish between the various types of abnormal lung sounds. As I have mentioned, a person with diminished lung sounds may have underlying wheezes and/or rales, and as soon as you administer albuterol, the patient begins to move more air, and those problems become apparent. in other words, you address one problem, and another may soon become apparent.

Good for you for exploring, asking questions, and trying to be a better provider. Keep up the good work.

[rock_shoes]

My pt. was talking in full sentences, was not using any excessory muscles to breath, had good skin color, SPO2 reading was good, and when I auscultated her lung sounds they sounded clear. ( But I am still learning how to diagnose the different lung sounds, so maybe I thought she had clear lung sounds, when the matter of fact she did have some mild wheezes.

All and all, it was a good call and I got her to the hospital where she could be taken care of and was able to go home a few hours later.

What are you using for a stethoscope? I can tell you from experience the Littman Classic II most BLS providers seem to use is great for taking a blood pressure but lousy for auscultating lung sounds. Not saying that's definitely the case but sometimes the problem isn't you it's the equipment you're using.

Kudos to you for asking the questions to do whatever you can to improve your practice.

Edited December 6, 2010 by rock_shoes

[PCP]

What are you using for a stethoscope? I can tell you from experience the Littman Classic II most BLS providers seem to use is great for taking a blood pressure but lousy for auscultating lung sounds. Not saying that's definitely the case but sometimes the problem isn't you it's the equipment you're using.

Kudos to you for asking the questions to do whatever you can to improve your practice.

Yes, I am using the Littman Classic II as most BLS providers use. I just feel I need more practice and that will come as do more calls. I want to be able to provide the best care to my pt. and I feel by being able to take a proper set of vitals including diagnosing lung sounds is VERY important to pt. care along with listening to my patient.