Inpatient Quality and

Safety Forum

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5.27.2021

Chava Cogan, PGY3

Managing Acute Changes

Chest pain, Shortness of breath and AMS

Chest Pain

Acute Chest Pain

It’s 1AM:

You get a haiku from the RN “patient complaining of chest pain, please come evaluate.”

You look at the handoff to remind

yourself who the patient

is and why they are admitted:

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“43 year old patient with HLD, HFrEF and hyperthyroidism

presenting after a fall, thought to be mechanical, admitted for syncopal workup”

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What do you want to do first?

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1. GET UPDATED VITAL SIGNS

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• Go SEE patient and do CV/Pulm exam

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Do you find evidence of cardiac ischemia leading to heart failure?

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Elevated JVP, third or fourth heart sounds, crackles in lungs,

symmetric leg edema, new mitral regurg

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Do you find evidence of another cardiovascular abnormality?

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Irregular heart beat, tachycardia/bradycardia (arrhythmia?)

Different blood pressures in arms (thoracic aortic dissection)

Decreased blood pressures in legs compared to arms (abdominal aortic dissection)

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Do you find evidence of pulmonary disease?

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Crackles/dullness/changes in fremitus (pneumonia or effusion)

Decreased breath sounds, asymmetric/tympanic chest (pneumothorax)

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Don’t forget to check for Homan’s (DVT/PE)

Acute Chest Pain - Differential

Acute Chest Pain - Differential

Acute Chest Pain - Differential

Acute Chest Pain - Differential

Acute Chest Pain - Differential

Acute Chest Pain - Differential

Acute Chest Pain - Differential

More History and ROS

If patient is stable…

...get more of the history.

Onset, Paliating/provoking factors, Quality, Radiation, Severity, Timing

• associated symptoms (SOB, diaphoresis, nausea etc…)

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Workup

ABG

BMP/CBC

CXR

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Quick Review

EKG

Always compare with priors if you can!

Obtain within 10 min of presentation and get serial EKGs (q1hr w/trop) to look for dynamic changes!

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Localize any ischemic changes

You get this EKG, and trop is 230, 2nd is 350 1 hour later

Clinical Stratification

STEMI (LEVEL 1 ACS)

• NEW LBBB or
• STE >1mm elevation (1 small box) in all leads except V2 and V3
• In V2 and V3 you need…
• >2mm for men ≥40
• >2.5mm for men <40
• >1.5mm for women

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Management

What people and interventions do you want to call for?

What medications do you want to give?

Any meds to avoid?

STEMI PAGER!

1. ASA 325mg
2. Nitrates for pain relief (unless taking Viagna/Ciaslis or Levitra within 48 hours)
3. Heparin drip
4. Antiplatelet (P2Y12), i.e. ticagrelor (look at protocol for contraindications), give LOADING DOSE
5. Beta blocker (unless hypotensive with pulmonary edema, severe brady,heart block, asthma or COPD)

Clinical Stratification

NSTEMI (LEVEL 2 ACS)

• ST ↓ > 0.5mm, or
• ST ↑ 0.6mm to < 1mm (or > 1mm which resolved in < 30 minutes), or
• TW ↓ > 1 mm, or
• Positive Troponin as per each assay’s Upper Limit of Normal (-T, or –I), or
• Unstable anginal history in a patient with CAD risk factors

If further risk stratification is needed, calculate TIMI and GRACE score.

If GRACE score > 140, treat as NSTEMI/UA and contact Cardiology for further recommendations (after speaking with on-call Family Medicine attending!).

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MUST discuss case with Fam Med attending on-call prior to call/paging a cardiology consult, but would be encouraged to call for potentially emergent cardiac catheterization if the patient has any of the following:

• refractory chest pain or suspected anginal equivalent, hemodynamic instability, acute heart failure, refractory ventricular arrhythmia, global ischemia (diffuse ST depression with ST elevation in aVR), Transient ST Elevation.

Management

What people and interventions do you want to call for?

What medications do you want to give?

Any meds to avoid?

• ASA 325mg
• Nitrates for pain relief (unless taking Viagna/Ciaslis or Levitra within 48 hours)
• Heparin drip
• Antiplatelet (P2Y12), i.e. ticagrelor (look at protocol for contraindications), ONLY load if already on agent at home OR if cath will be delayed >12 hours (so basically load most of our patients with NSTEMI at the Allen)
• Beta blocker (unless hypotensive with pulmonary edema, severe brady,heart block, asthma or COPD)

Clinical Stratification

Atypical Chest Pain (LEVEL 3 ACS)

• Normal or non-diagnostic EKG +/- chest pain without alternative explanation

Consider stress testing if troponins remain not too elevated .

Use HEART or EDACS score to determine if admission or additional cardiac testing is needed to predict risk of future cardiac events.

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ACS: Resources

Altered Mental

Status

Acute AMS

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It’s 5AM:

You get a haiku from the RN “I am worried about this patient’s mental status. Please assist.”

Like before, you glance at the handoff to remind

yourself who the patient

is and why they are admitted:

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“83 year old patient with DM2, HTN and ESRD presenting with palpitations, found to have new onset afib, admitted for further management”

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What do you want to do first?

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• GET UPDATED VITAL SIGNS - including POC BLOOD SUGAR

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• KEY questions:
1. Last known normal? Defining the temporal course
2. Baseline? Important to establish during sign out as well

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• Go SEE patient and do NEURO exam

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Check Pulse ox, breathing and circulatory status (hypoxia or hypercapnia)

Check for post-ictal signs (loss of bowel or bladder tone, lingual trauma, nystagmus or fasciculations)

Check for spontaneous movements (or lack thereof) and any new focal deficits

Check pupillary response, look for nystagmus

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Differential - Altered Mental Status

Differential - Altered Mental Status

Differential - Altered Mental Status

Differential - Altered Mental Status

Differential - Altered Mental Status

Differential - Altered Mental Status

Next steps

Change in neuro exam: CVA? (call STROKE CODE; stat HCT without contrast)

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ESRD: uremic? (need HD)

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DM: hypoglycemic? (amp of D5)

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Cirrhosis: hepatic encephalopathy? (start or increase lactulose)

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COPD: hypercapnea? (trial bipap if not too altered, but would low threshold to intubate)

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Recent meds? Opiates (give narcan if depressed RR or retaining CO2)

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Infection? Pan-culture, ABG+ lactate, CXR, low threshold to start appropriate antibiotics (broad spectrum)

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Workup

Non-contrast CT head

EKG +/- trop

CBC/BMP

LFTS

ABG + lactate

CXR?

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Delirium v. Dementia v. Psychosis

Shortness

of Breath

Acute SOB

Now it’s 7AM:

You get a haiku from the RN “patient complaining of SOB, please come to bedside.”

Again, you look at the handoff:

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“77 year old patient with HLD, history of breast cancer (now in remission) and severe dementia, presenting from assisted living with AMS, found to have UTI, dispo pending placement”

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What do you want to do first?

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• GET UPDATED VITAL SIGNS (special attention to RR and SpO2)

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• Go SEE patient and do CV/PULM exam

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Check Pulse ox (ensure good waveform)

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Monitor breathing (respiratory muscle use)

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Check circulatory status (pulses)

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Check for Homan’s sign

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Consider STAT ABG

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Differential - Shortness of Breath

Differential - Shortness of Breath

Differential - Shortness of Breath

Differential - Shortness of Breath

Differential - Shortness of Breath

Differential - Shortness of Breath

Differential - Shortness of Breath

Workup

CXR

ABG + lactate

EKG +/- trop

CBC/BMP

pro-BNP

Procal

D-dimer?

CTA-PE?

Supplemental O2

Is patient hypoxic? If yes, increase FiO2

Is the patient not able to breathe adequately? If no, supplement respiratory efforts.

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Hypoxemia: Goal O2 saturation >92% in most patients; for COPD goal 88-92% check for a good waveform on monitor!

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Hypercapnea

Determine acuity: check baseline pCO2 as well as pt’s pH and HCO3. If normal pH and elevated bicarb, then hypercapnea is likely chronic.

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If worsening, trial BiPAP if no contraindications. Trend pCO2 on serial gases.

If pCO2 does not improve, then pt likely requires intubation

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Up-titration of oxygen in hypoxemia:

NC (can go up to 6L) → facemask (can deliver 6-12L O2, 35-60% FiO2) or NRB (10-15L, 100% FiO2) HFNC (up to 60L, 30-100%FiO2) → if pure hypoxia (no hypercarbia on gas), then should be intubated, as NIPPV will not provide significant benefit

Respiratory Support

NIPPV

Indications: hypercapnea with COPD, cardiogenic pulmonary edema, moderate to severe dyspnea with increased WOB

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Contraindications: severe AMS, vomiting, copious secretions, inability to protect airway, HD instability, severe UGIB, poor mask fit

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Monitoring: trend blood gas (PCO2) to ensure respiratory acidosis improving

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Need for Intubation?

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Ask yourself 4 questions:

1. Failure of airway maintenance or protection? (AMS, inability to clear secretions)
2. Failure of of oxygenation? (Remains hypoxic after brief trial of BIPAP)
3. Failure of ventilation? (pCO2 did not improve with BIPAP)
4. Is there an anticipated need for intubation? (Increased work of breathing)

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THANK YOU!