A 48-year-old female sits in her kitchen, on the edge of her chair leaning against the table. As you approach her, she tells you she can’t catch her breath. She’s in obvious distress, but is able to tell you her shortness of breath began this morning and has become increasingly severe over the past four hours before finally calling 9-1-1.
Your partner quickly prepares a non-rebreather oxygen mask while you apply the pulse oximeter, which reads 93% on room air. The oxygen mask is placed on the patient and she tells you it’s helping a little bit. Your partner looks at you and asks, “What’s next?”
There are multiple conditions that may be causing this patient presentation. The patient could be experiencing a myocardial infarction (MI), she may have thrown a pulmonary embolism (PE), have pneumonia or have had an allergic reaction. Differentiating between these conditions and others is important for EMS providers as treatments vary between various causes.
For example, an allergic reaction would benefit from the administration of epinephrine, but epinephrine could be harmful if the patient was having an MI. A complete history and thorough assessment helps providers determine underlying causes and establish treatment plans.
EMS providers should begin their assessment as they first approach the patient. React to life threats as they present. In this case, the patient presented in obvious respiratory distress and received high-flow oxygen soon after EMS arrived, which relieved some of her dyspnea. After managing life threats, determining a patient’s history of dyspnea onset is helpful. PEs and MIs typically have sudden onsets, whereas pneumonia, pericardial tamponade and anemia affect patients gradually. Histories of clotting disorders, long periods of immobilization, heart disease and recent colds or flu may help identify potential causes.
Providers should remember, however, a patient doesn’t have to have a history of heart disease in order to have an MI, nor do they need to be immobile for long periods of time to throw a PE. Also ask about associated signs and symptoms—PEs may have pleuritic pain and MIs may also present with pain and commonly present with diaphoresis. Pneumonia may have a cough, producing yellowish green and, sometimes, blood-tinged mucous.
A physical exam is crucial in helping determine cause of distress and treatment. Auscultation of lung sounds may be the most important exam done on a patient in respiratory distress and should be done early.
When auscultating the chest of a patient in respiratory distress, the stethoscope should be placed on the skin rather than attempting to listen through clothes. There are a couple versions of auscultation patterns but providers should generally begin by listening at the apex of the lung. Place the stethoscope at the midpoint just below the clavicle, and listen to one complete respiratory cycle. Then move the stethoscope to the other side of the chest at the same location and listen to one complete respiratory cycle. Move the stethoscope down a couple of ribs and listen again. Move to the other side of the chest at the same location and, again, listen to one complete respiratory cycle.
Five or six sites can be auscultated on each side of the chest. Remember, the diaphragm is at the level of the xiphoid process at the anterior chest, and listening below that margin will be too low to hear lung sounds. Move to the back of the chest and place your stethoscope high, between the scapula and spinal column.
Move to the other side of the back at the same location and listen again. Repeat this sequence down the back, again listening to 5–6 places on each side of the chest, including the lateral regions. This may seem extensive, but when patients are complaining of dyspnea, the organ affected is commonly the lungs. They should be assessed thoroughly.
With cardiac pulmonary edema, crackles will be heard in the bases. If the patient is having an asthma attack, wheezing can be heard diffusely through the lungs. Allergic reactions can present with diffuse wheezing and can also have stridorous sounds in the trachea and main stem bronchus.
Pneumonia will have crackles and/or wheezes in a local area where the infection is located, and PEs will initially present with clear lung sounds. The type and location of adventitious lung sound will help identify the cause of dyspnea. Don’t forget pulse oximetry and capnography readings. When assessing a patient with shortness of breath, both of these values can be helpful.
For example, in a patient experiencing an asthma attack, the pulse oximetry will likely be low and the capnography will be high. Patients with PEs may have normal or slightly lower pulse oximetry and low capnography readings as well. Providers should evaluate both readings and consider them together in their evaluation.
All levels of EMS providers should be able to obtain a relevant history, perform a thorough assessment and understand at least the basics as they pertain to readings such as pulse oximetry and capnography. Providers should remember there isn’t one “silver bullet” when assessing patients. Mindful assessment and correct treatment all add up to positive patient outcome.