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Hello, everyone. Welcome to our uh medical education event today. We're doing acute breathlessness with Sano. Um As always pop your questions in the chat, we want lots and lots of questions and at the end of the event, the feedback will come and your emails and your attendance certificate will be on your med account. There might be a slight delay in um getting this event as catch up because I've got a few to do because I had to take some time off. So I've still got a few to do, but I will get it up for you. All right. So without further ado, I'm gonna hand you over to hi, good afternoon uh from UK. Uh but I, I can understand this, lots of people from lots of countries um for those who, you know, saw me and he heard my presentation on trauma and so good morning, good evening, good night. Wherever you are. Welcome to this uh this talk. Uh And as as you said, this is talking about how you would assess and how you would manage a patient with who is acutely short of breath or acute breathlessness. As I mean, as I understand. Um, so I'm an Emerson medicine consultant and I'll only touch on the acute situation rather than going on the chronic next. So what we're going to do in this is in this hour, we're going to talk about what is breathlessness. What do you understand by that? Then we're going to look at a safe approach to a patient who is breathless and, and, and those are the, the causes of breathlessness that will kill the patient, which are life threatening. Also not forgetting that if you, once you've dealt with the life threatening, there's also some causes of breathlessness which are potentially life threatening. You still got to be aware of that and we look at that and then we'll summarize and let you have ask some questions. Ok. Next, OK. Right. As you can see in the picture that, that that patient, that guy um must have either walked or run and he seems breathless. So just, you know, on the chat box. Um What do you understand by breathlessness? What do you understand by shortness of breath? I suppose those who are on on online uh myself included. I I we are not breathless, are we so why not? And what we are breathless um would look like any thoughts. How would you know it, how would you know the severity of breathlessness? Just few and then we'll move on few comments, few answers, your thoughts. I think everyone needs some caffeine there. We go. Yes. OK. So fast respiratory rate. Ok. So what fast rate maybe? Yeah. OK. Um increased respiratory rate. Difficulty breathing. Yeah, that's what breathlessness is. Accessory muscle working brilliant. OK. So um yeah. Ok. OK. Um Breathing difficult man. Movement of the thorax, OK. Color of the skin. Ok. Agitated. So what they say is so if, if we are not breathless now, OK, then if somebody is breathless, we are breathing that 21% oxygen in the atmosphere, it is coming through a nose or mouth and through patent airway, going down the trache into the lungs and, and enabling the lungs to ventilate. Ok? Now, if that 21% is not enough. Yeah. And we think we need more of that oxygen. They will demonstrate that breathlessness and what will they say to us? They, they'll either say or demonstrate. I'm I've got air hunger hungry for air. What what? Actually he is hungry for oxygen. Ok? I'm feeling choked. OK? II I can't breathe. Yeah, I can't breathe. Ok. So, so it's now when we, when we are breathing all of us now including su um we are not aware of our breathing. Would that be right? We, we, we, we are not aware when breathlessness happen. When breathlessness happens, then the person becomes aware of their breathing effort and the efficacy. Ok? And that comes out as hunger for oxygen. I can't, I feel choked. Um I need more air. I'm gasping. That's another word they say. Ok, so, so, so that's what you need to be aware of, to say, to see. And then when they are breathless, um, that's how, you know, and then in terms of severity, how, you know, some, some of you have said accessory muscles. Yeah. Ok. So normal breathing muscle is the diaphragm and the, that, that's the main breathing muscles and some, what are the accessory muscles? Then, er, those who have said accessory muscles, any, any thoughts they will start working because the normal breathing muscles is not enough, the accessory muscles start coming in into action. And what will you see intercostal muscles? Absolutely. Intercostal and what you see in Children, especially that they, you have intercostal recession. Yeah. So when you're breathing in the, the muscles, intercostal muscles get sucked in due to negative pressure. So, intercostal recession, you get sternal recession, subcostal, uh you know, suction, um, sternocleidomastoid, you can see them working. Yeah, or trapezius, for instance, nasal alli, you can see flaring, ok. Flaring of the alli, OK. And, and so forth. So they start working and also you can see what other things can you see? Like I'm talking now, I won't be able to talk. I might be able to talk. So I might say my name, my name is, but I can't finish the sentence. So my name is, and, and they can't finish the sentence. So if somebody's talking, their airway is patent, ok? But they may not be but, but it doesn't, it doesn't mean airways obstructed, but it means they're distressed with breathing. Ok. So hope that sets the scene in terms of what breathlessness is next. Now, how would you approach somebody who is breathless, who is short of breath? And again, remember the talk on trauma, those who are there, the safe approach is what we call primary survey. It's those five letters of the alphabet, the airway, breathing, circulation, disability, and event, and environment. Ok. So what we need to do is we're going to concentrate on b because breathless, breathlessness is all about breathing and ventilation. And we, you know what, what that means is the breathing is caused by the breathing mechanics. Yeah, the muscles, the nervous system, et cetera ventilation. That is gas exchange does happens at the alveolar blood level. Yeah. So the lungs are covered by blood vessels. The the gas exchange happens at that level. So you may have an intact airway but you may not be breathing, right? Ok. Because of say chest trauma, you may be short of breath, you may be breathing, ok? But you may not be ventilating, right? And that's to do with mismatch of the ventilation and perfusion uh ratio the VQ as we say. Yeah, and there are several causes which cause that. So first of all, we need to assess the airway because if the airway is obstructed, the oxygen won't go in. So forget, but so you won't be able to breathe anywhere. Ok. So how you do that in this, in this primary survey? You do it using simple senses. There's no, uh, highed investigations. You use your skills and competencies. Um, so LLF is, look, listen, feel. Ok. So you look for, what do you look for? You look for obstructed airway sounds and what are the obstructed airway? Sounds? Any thoughts? Upper airway? I'm talking about upper airway. Stridor. Excellent. So, Stridor is a, is an obstructed uh due to dry obstruction. If it's wet, obstruction by fluid or blood or whatever, you'll get gurgling. Snoring is and why does that happen? The commonest reason the tongue falls back and slaps on the larynx. That's why you get Stridor. So listen again, you hear the noise, the Stridor that's dried up. Then you have the hoarse voice um with the inflammation of the larynx choking. Yeah. Ok. Somebody says to bu and then you feel what you feel you feel, bring your hand close to the mouth and can you, he can you feel the breaths coming out? Ok. Once you suspect, so you could, the airway has to be open and you have to maintain it open and if it's obstructed. So let's say you've got an obstructed airway sound means the the tongue is falling back. You do some maneuvers. You, you, you do a head tilt, you can do a chin lift. Um you know, head tilt, chin lift, er, or jaw thrust to open the airway. If that doesn't work, then you put some, uh, you, you got to use some adjuncts. Yeah, I haven't got that with me. So, what we call is oropharyngeal airway goes to the mouth. Nasopharyngeal airway, if they can't tolerate, or the airway is still obstructed, then you might have to look inside by a direct laryngoscope to see if there's any foreign body obstructing the larynx. And I'll share an example with you. We had a patient who came with choking, an elderly patient. Um, and um, the, the, the he was virtually on the, on the, on the, on the, on the verge of stopping breathing. So we called the anesthetist who tried to put a tube in and the tube wouldn't go down the trachea. And um before then the, the patient was ventilated and paralyzed with drugs. So because they couldn't get the, the tube in the patient stopped breathing. So we had to do something. So what we did was we did a, a cricothyroidotomy and put a tracheostomy tube and the patient survived. And when we had a look properly, which then he said he should have had a look. There was a big mass over the larynx. He had a laryngeal C A. So foreign body can cause obstruction. Now, if it's in the mouth in an adult, you can do a finger sweep, stick your finger and, and take it out in a child you don't do that in a child. You do use a mcgill's Forceps and take the foreign body out. Yeah. So that's airway. Now, um, I, if, if, if it's caused by trauma and one of the, one of the common causes that can happen is AAA sta a penetrating or a blunt trauma to the larynx, then the patient might need ent surgeons to, to sort that out in theaters before the airways are open. Yeah. Now once the airway is sorted, then you come to breathing and ventilation and, and you already said how you can assess the ventilation. So the way you can assess is as you can see LFP and, and again, using your simple senses, you look, inspect, you listen, you sculpt it um by the stethoscope, this is where you use it, you feel you palpate and you percuss. So you percuss to either detect is the air in the pleur pleural space or there's fluid or blood. In the case of trauma. The two observations that you need to be aware of that can help you is the respiratory rate. Some of some of you have said that and the spo two, which is the uh you know oxygen saturation. Now remember uh respiratory rate both you know the normal, yeah, you know the normal, if it's tachypnea, which is high respiratory, that's worrying because that means the the the 21% is not enough. So they're breathing fast to make, make use of that oxygen. Yeah. Um Now if they keep breathe, doing that, breathing fast, accessory muscles, working what will happen? They become exhausted when the patient becomes exhausted, the respiratory rate goes down or let's say they've taken some medication that depresses the respiratory center. So the breathing rate will go down. So both tachypnea and bradypnea are are worse. Um in terms of saturation spo two, now remember, saturation does tell you about the oxygen concentration in the lungs. It gives you no idea about the ventilation that's going on at the gas exchange level. Yeah, for that, you need what to give you an idea of ventilation. What do you need? What do you need to do? You need an investigation? AB BG. Excellent cy and linde, you need an arterial blood gas. Now, commonly we tend to do more venous blood gas than arterial, but this is an instance in a breathless patient. When you want to know the ventilation going on, you need an ABG you know, by radial or brachial or wherever. Ok. Now, circulation, we don't going to spend too much time on it uh because we're going to go through the causes and treatment. Um Remember uh uh a cause of breathless is that can cause shock. You will see the features of shock in circulation. So you might see tachycardia, you might see low BP, uh pro cap refill time, et cetera. Ok. Disability. Again, the G CS can be impacted with somebody who is breathless because if they are not saturating, well then no less oxygen going to the brain, the G CS can go down or respiratory center uh suppressed by drugs or, or, or a disease condition can lower the GC S. So it's important to er, look at the GC S and the ease your event, you know. Uh it, it's what you go, what do you find through history? What's happened? Um You know, and, and not forgetting temperature and blood sugar? OK. Next. So now this is a bit of uh I need your help here. Um Now, lifethreatening causes of breathlessness can be medical can be traumatic. So let's deal with it each. So some now they're not lifethreatening cause are not many that these are causes which if you suspect you've got to treat them right away. If you don't, then the patient will die in front of you. That's how important time is of essence. Remember time is ticking away. So some causes of life threatening. Any thoughts quickly, tension, pneumothorax, excellent anaphylaxis, lifethreatening, asthma, linde, wonderful and asthma exacerbation status, asthmatic and brilliant, brilliant. OK. OK. Right. Next, pulmonary embolism. So here, so some of you have already mentioned those courses. Now, pneumothorax per se will not cause lifethreatening, breathlessness, they will cause breathlessness, but it's the tension pneumothorax that causes the lifethreatening. So these are patients who will be in recess in an emergency room or an emergency department asthmatics normally will cause breathlessness, but it depends on the severity. You know, the asthma has got, uh, the British Thoracic Society classifies asthma into four categories, mild, moderate, severe lifethreatening. It's the life threatening one that will kill the patient if you don't recognize and treat it, the others can be dealt with with through medications. Now, one of the things that can happen is patients who are known to have heart failure, they can develop acute left ventricular failure or acute heart failure. That is a life-threatening cause anaphylaxis. Somebody has said yes, it it's a killer exacerbation of COPD. Now COPD again, it has to be severe life-threatening. COPD that can cause um you know, breathlessness in the life-threatening and can kill the patient. A pneumonia which is lung infection normally doesn't cause life-threatening, bless breathlessness, but a severe pneumonia can cause that. Now some of you have said pe e excellent, but in terms of pulmonary embolus, most of the time we get minor pe or suspected pe. But if there is a life threatening major pee. So how would you know that a pulmonary emus would cause hemody instability? That's a life threatening major pe that will cause a life threatening, breathless and, and some of you mentioned COVID, it's, it's gone. Now still COVID is there, it's not gone completely, but we are not seeing that severe um uh breathlessness with COVID. They, they, they do come in with infection, but we're not seeing that severe breathlessness like we used to see in the pee. Now what we're gonna do now uh next to thank you for that. So, um those are some of the causes I I've just put some pictures up. What we're going to do is take each one of them and um with your help, we're going to diagnose clinically and maybe, maybe we'll use some bedside investigation and you and we're going to discuss treatment. Yeah. So these are the medical reasons. Let's pay attention. Pneumothorax. Ok. How will you diagnose? This is a breathless patient. We know and it's based on your clinical assessment. Ok. So you look, listen, feel and cu you've done that the patient is tachy, the saturation is low is below 95. Remember in a, in a, in a, in a normal patient uh without COPD, the target saturation is always up to 95 beyond that. But in the COPD, it's less but your initial treatment, oxygen is high flow and then you titrate. So, so tension pneumothorax, what will you find any thoughts? Trachea, brachial injury? Yeah. Absent lung sound, a deviated trachea. So, ok. So trachea, deviated, sternal deviation to the healthy side away from the er er affected side. And when you listen, this is not reduced breath sound, this is absent breath, sounds, no breath sounds at all. So when somebody comes and tells me I can't hear breath sounds, I'm worried because is that tension Thora going on and EOR neck veins. Yes, because of the uh pressure on the super Vena caval pressure and, and, and what it does is this pressure on the superior vena cava and gets reflected through ego neck veins. Ok? And when you percuss, it will be high mean because it, the lung is full of air, the lung tissue is virtually reduced to a small amount. Now, when you get that, uh you need immediate treatment and what's the immediate treatment? Yeah, hypotension, tachycardia. So the patient will be in shock. Ok. A a shocked patient with all those features is a tension pneumothorax who is breathless. And what you do is what we call needle thoracocentesis or Mohammad. They said large bone injection. So what you mean what what he means I think is take a large bow cannula and you do needle thoracocentesis. So you go through, yes. Mon says thoracocentesis go through midclavicular line, second, intercostal space above the second rib to avoid neurovascular damage, you go through the skin. So you connect it to a syringe, you go through the skin intercostal muscles and into the pleural space. The pressure is so much, you can immediately aspirate air and once you detach you'll hear a hiss, you aspirate as much air as you can and then follow that up with a chest drain. Ok? That's the definitive. OK. We have no time to discuss the technique but a chest drain has to be through the same side fios space in the, in the anterior axillary line. Yeah, with a, with a Zel A technique. This is uh medical, this is spontaneous pneumothorax. It's a seldinger needle that we use. Ok. The next one is acute um heart failure. Now, those who are known heart failure, they'll have some symptoms or signs of heart failure like pedal edema. Um you know, um raised JVP um and, and liver enlargement. But how do you know uh they are in acute heart failure? They'll be acutely short of breath and they could be in shock as well because this is cardiogenic shock. The heart is failing, they're not pumping enough. So you will have a, a sweaty uh sitting up patient who is really difficult to breathe and they're cold in peripheries because they are shocked and you, you, you, when you listen to the lungs, what you hear is crackles. The crackling is because of interstitial fluid caused by fluid overload. Ok. What would you do? They need oxygen. All these patients need oxygen. I'm not going to mention again, high flow oxygen, but specifically in heart failure, you need to uh reduce their preload. So what you do is give them some nitrates either by orally or intravenous. If they are hypotensive, you don't give too much of fluid, but you can give small amount of crystalloid as a fluid challenge to see whether they make a, make a difference. What if you want to give more fluids. You really need a central line to monitor the CV P. OK. You need diuretics to drain the water. But remember they might need catheter because it will stimulate uh them, them sense of passing urine and because they are anxious, they have an impending sense of death. You might need to give some anxiolytics. And the classical one we use is either diamorphine or simple morphine in small doses, intravenous. Ok. Um Coming to so if you go back to the previous slide, um so please, OK. So the lifethreatening asthma, we'll stay on this slide. How do you diagnose again? I said asthma, they're breathless. Um Yes, Mohammed. But initial you, your initial oxygen is high flow. Once you get to know the patient is COPD, then you titrate it, then you ti titrate to up to 88%. You don't give any more than that. So if the saturation is 88 you don't want to increase any further, you don't want to maybe give any further oxygen. I'll come to COPD in a minute, coming to asthma. So they are breathless. And how do you know how do you decide the severity? It's based on two things. One is their symptoms, one is their vital signs. So, tachypnea, tachycardia and also the peak flow. This is a bedside test that you can do. Now, somebody who's life threatening, you forget you, they can't do a peak flow, even severe asthmatics, they can't. So a lifethreatening asthma would be, er, they can't talk because they have, they can't talk. There's so much in distress, their lung is silent. They may be cyanotic. These are all preterminal signs. What I mean is preterminal is if you see an asthmatic who is silent chest and they're cyanotic, they are not very far from a respiratory arrest. So you got, you really got to get your act together and be ready to put a tube in to help them breathe by, when, by by mechanical vel nation. So um so silent chest uh they they could be cyanotic. You can't even hear a wheeze. Yeah, but you get a history of asthma. So what do you do? You give them treatment wise? What do you do? You give them bronchodilators, you give them steroids because in asthma you've got to give a two prong attack. One is a bronchodilator because there's bronchospasm and there is inflammation due to complement cascade. You give steroids and you give back to back, you give back to back one after the other one after the other. If they're not working, then you can go to the next. So what's the third line drug in this situation? What would you do? What would you give any drug that you can think of used? It's, it's evidence based. Mm Mani superb magnesium. So you can give magnesium uh 20 mg over two hours but you need to monitor the cardiac rhythm, magnesium sulfate. If and there is some anecdotal evidence you can use, uh, if magnesium doesn't work and the nebs are not working and they are still breathless. Um, you can use um, aminophyllin as well. Yeah, I mean, it's a theophylline but uh, so that, that's, but, but it's more used in, in COPD. Ok. So that's life threatening asthma anaphylaxis. Again, you got to differentiate between anaphylaxis and allergic reaction. Now, when you say anaphylaxis, there is a history of allergic reaction to a drug or food or whatever. They are breathless. But what are the features of anaphylaxis? One is breathlessness. They have bronchospasm, they might have tachycardia and hypotension. So they could be in shock and they could have a widespread artic rash. Any of those with the allergic history is anaphylaxis. And once you think that Tibet Tibe has said that's the drug first line adrenaline get the adrenaline. Now, patient might have already used if they're known allergic, they might already have their own EpiPen. This is their own pen is uh adrenaline, but we have to give adrenaline. Now, the adrenaline that you give has got a specific dose, strength and root anyone. Any thoughts, dose strength and root. Ok. Um One in 1000 excellent. It's intramuscular and it's um 0.5 mils. Ok. Um, now there's no rule of IV here but uh, research Council in UK has said that you can repeat it. Yeah, can repeat and, and you might have to give IV fluids. If they're in shock, you might have to in, in terms of breathlessness because the bronchospasm you have to give nebulizers as well. Ok. And steroids as well coming to severe COPD already, some, some of you have mentioned this is severe or lifethreatening. The features are exactly like life-threatening, asthma. You may not, you might have, you might listen to wheeze, you may not have, you may have a silent chest, but you have a history of COPD. OK. So titrate the oxygen once you get to know that again, treatment is back to back nebulizers. So this nebulizer. So, so remember in asthma, we start off with AAA salbutamol, then we go to Ipratropium bromide. Whereas in, in COPD, you give salbutamol and IPI bromide together that's evidence based and you give back to back, you give steroid as well. OK? Because there's inflammatory component and if that's not working the third line drug evidence based is aminophylline. Now, there's something you've got to make sure when you give aminophylline, you give it two ways, you can give a bolus and you can give infusion. Now, if they're already on theophylline, avoid the bolus because it's cardiotoxic, you give infusion. If they're not on theophylline, you find out through the drug history, you can give the bolus. OK? And, but if that doesn't work, so that's the medical management. OK. But there's a ventilatory management as well, which is somebody has mentioned uh you know uh saying NIVV. So NIV is noninvasive ventilation. Th this is using a noninvasive ventilation. Um instru you know, equipment which is set at, at certain like, you know, we got no time to talk through. So you put them on bipap by, in, in, you know, phasic uh ventilation, whereas in acute LVF, you can still use NIV, what you do is CPAP is continuous positive airway pressure ventilation. Now, the reason you don't give what you don't do, you try your best to avoid invasive ventilation, invasive ventilation is by putting a tube in the trachea and connecting to a ventilator. Asthmatics will need that because they're usually young in COPD. What you want is if you, if you give them invasive ventilation, you won't be able to wean them, you can't take the tube out because they become dependent on it and also it increases the hospital stay. So both of those reasons, you try niv severe pneumonia again. What are the features of pneumonia? How would you know somebody's got pneumonia? They are breathless. Plus what? Quickly? I think it's taking a bit of time to come through but it will come through. Yeah. So what fever? Excellent. They are pyrexia. They are coughing, they're coughing, sputum and the color of the sputum. You know, they could have chest pain. He has pleural involvement so they can have a green brown, whatever or maybe a bit of blood coming out. Specks of blood. Uh and, and, and they may be in sepsis. That's the other thing to find out. Even a COPD could be in infective sepsis. So, if they in sepsis, you start the sepsis bundle. Ok. Which is uh antibiotic, you send blood cultures, you take bloods for, you know, full blood count. Uh, you know, and s um coagulation screen, et cetera. Uh, in COPD, in pneumonia, you, again, there could be in sepsis. You start the sepsis bundle, sepsis bundle means you start the antibiotic within an hour. Er with you don't know the, you don't know the bug. It could be uh uh bacteria, it could be viral but you don't know. So you've got to give something and, and that's based on the severity. The severity is based on a score which the British Thoracic society uses called what a scoring system to decide. Absolutely. Sund done. SCP 65. So let's explore that that's a scoring system where you use um decide the severity. So, C is for confusion. U is for urea above seven respiratory rate, more than 30 BP, systolic, less than 98 65. The higher this curb 65. So you get a score of five, it it's linked to mortality. Yeah. So zero, curb mortality is 0.7% if it's five, mortality is about more than 50%. So again, you need antibiotic and back to back nebulizer steroids, et cetera. Consider niv now to decide niv you need clinical features that they're not settling with the medical therapy. Plus you need to demonstrate that they are in which type of respiratory failure they will be in respiratory failure before you decide. Niv, that's the, that's why you give an IV. What type of respiratory fail are these prone to these patients? Type two? Mui excellent. So type one is where usually in asthmatics or other metabolic reasons, you can get um just hypoxemia. But when you go, so in type two, what you get is a respiratory acidosis. So when you do ABG, you'll see low Ph and CO2, if they're chronic, you might see increase in bicarbonate. So in type two, respiratory failure, you give them an IV last one, life threatening pe now pe is a diagnosis of suspicion. The only way to confirm is by imaging. So how do you suspect each of the symptom or signs will increase the likelihood? So what symptoms they are breathless? So unexplained, breathless. So you're racking your brains, you go through all of those reasons before you can't find a reason. Sudden. Acute, unexplained breathless. Think be ok. If you don't, you'll be missing a diagnosis. Ok. What else? Chest pain, anything about the chest pain in b what kind of chest pain? Pic? Ok. Yeah. Pruritic chest pain, what else can happen? Hemoptysis? There can be, yeah, hemoptysis. Um and shortness of breath. Now, then what you do you look at, you know there will be tachy, there will be tachycardic and then you, you know, do you do to look at the, look at the likelihood you do a pretest probability scoring system, what we use in, in UK, the Nice Garden recommends using Wellco. And there's the, there's a score decided by um you know, if it's less than four, then it's a low risk and, and if it's more than four and above, then you do. Yeah, you do other investigation like ECG the, the uh Tala, the S one Q three T three is very rare. The commonest uh finding in ECG is tachycardia. That's what you look for. Uh and, and well score. Yeah. OK. So you treat them because you don't wait for proof in, especially in a, in an, in a, in a life threatening pea, you will have uh the patient will be hemodia unstable. They will be in shock. We have seen in, in our research room patients coming with cardiac arrest and that's what you be aware of that. If they are in cardiac arrest, you think they are, they have had a P your your prolonged resuscitation starts, you might have to thromb the patient using TPA. Um But if they're not in cardiac arrest, you, you give them thrombolysis. OK, which is by um Heparin, then you organize the investigation. The the gold standard investigation is what in to diagnose pe chest x-ray doesn't diagnose pe, it can show some. Um Yeah, CT P goes without saying so we got to do CT P. Uh chest x-ray only shows um, a VQ mismatch or an oligemia peripherally. But that's it. Uh, it can show you other findings that in infection and COVID-19, I'm not going to dwell on it. Um I, I've got some x-rays to show you next one and, and next one. So hope that was a, some, uh, you know, a discussion about medical. Um OK, so these are the traumatic reasons of lifethreatening, breathlessness. Those were the medical, these are the traumatic somebody who's had a blunt trauma or a penetrating trauma. Again, tension pneumothorax, we've dealt with it. We, we've decided, we, we've discussed how you can diagnose it and what you're going to treat, followed by chest pain. Now, the others, the massive hemothorax, flail chest, open pneumothorax, cardia, Tana. Um uh So let's let's go through those come to massive hemothorax when you call, somebody has got massive hemothorax. This is usually a blunt trauma or even a penetrating trauma to the chest where the hemi Thax is full of blood to say it's massive. You need to have about 2.5 liters of blood in the lungs. Now, how do you know that you don't, you can't know from outside, but the patient will be in shock because of massive blood loss. And one of the things just want you to remember is these classes of shock, hemorrhagic shock, you know, class one to class four, depending on the percentage of volume loss, blood loss in this patient, massive hemothorax. You will have, it's a class I shock where they lost about 30% of the blood volume. Their systolic BP goes down. Remember in a shocked patient, the first sign is tachycardia. Then further blood loss, there is diastolic pressure goes down and there's a, there's a fall in pulse pressure in class three, there is a drop in systolic. So to have a systolic pressure drop, you need to lose about 2, 2.5 liters of blood and you can't wait for that. So if somebody is in shock, how do you know that they are tachycardia? They're cold. A shock patient is cold with a trauma history with breathlessness. You suspecting massive thorax, hemothorax, start shock therapy and we talked about in trauma. Remember those who were in my trauma talk, you start the shock therapy by getting access a big cannula or whatever cannula you can get, take some bloods including cross match. Then you put some fluids. Now you don't, you don't put massive amounts of fluids. You put some ringer, you put some crystalloids about 500 mils as a challenge. But you send for um massive hemorrhage protocol which brings back blood and uh you know, red cells and FF which you can start once you start the shock therapy, then you think there's massive hemothorax. You can do a quick ultrasound bedside and then what it needs is a, is a, is a chest drain. Now, chest drain, once you put the drain in, you can see a blood coming out if there is a massive amount of blood coming out, splashing on the flow about a liter, liter and a half. That patient will need a cardiothoracic surgeon. If you have it in the hospital or you send the patient, transfer the patient to a center or major trauma center. If they are not splashing blood, that amount you, you watch and wait to see how much the blood loss is. Yeah. Is it if it's about 2, 202 102 50 miles an hour again, that patient will need, they need their chest opening because there is some bleeding sites that need closing. Remember in a hemorrhagic shock, it's not only good enough to start the shock therapy, you have to stop the bleeding what we call closing the tap. OK. Flail chest. OK. Uh Next line, if you see this uh the top left diagram. So the middle diagram is hemothorax. You can see the block, the top left. Can you see that diagram uh usually caused by blunt trauma, you got multiple rib fractures. But one classical thing has to happen is the rib has to be broken in two or more places, then only you'll have a flail segment. OK. Yeah. If you close the top, the flail segment is a segment of the, of the, of the chest wall that doesn't participate in the respiration. Ok. So what will happen is when you're breathing in that, that segment will suck, get sucked in by the negative pressure and vice versa. So that results in what when you look at the chest wall, what do you see in a flail segment? What kind of breathing it's called any thoughts? Paradoxical breathing? Excellent. So that's a feature of, of, of, of flail segment. And what you need to do is um they are in severe pain. So the main stay is giving them oxygen and giving them analgesia. Now, intravenous analgesia, this is not, you know, paracetamol, this is intravenous opiates or you might have to get help of the anesthetics to give intercostal block or epidural block. They need to be in, in, in intensive care. Now, one of the things this injury does they cause bruising to the lungs and that results in hypoxia. So that oxygen is important, they might cause pneumothorax or hemothorax. You might have to put a drain in. But if you are in ventilating, such patient in a flail segment, remember, positive pressure ventilation can cause pneumothorax. So you might have to give uh put a drain in prophylactically to prevent pneumothorax. Ok. The next one is open pneumothorax. Some of you have said again, the the way it happens is penetrating chest trauma um where you have a wound which is sucking, be sucking because the atmospheric pressure is making the wound look like it's sucking, it's drawing air and that can cause collapse of the lung. And you have a wound that can reach anywhere. You don't know where the wound is going and you have a pneumothorax. So how will you treat? You need to treat the pneumothorax with the drain? But that wound you need covering temporarily because that wound will need surgery by the chest um surgeon, thoracic surgeon. So um I think mani talks about ball valve mechanism. So what you do is you cover the wound on only three sides. So imagine the wound is a square, you only cover three sides leaving one side open to prevent tension, pneumothorax developing. Ok. So only cover three sides um until the wound is sorted. So remember they need antibiotic because a dirty wound three wear dressing. The ba who says um because you need a dress, you need antibiotics, tetanus cover, et cetera. Ok. The last one I'm going to uh uh mention is cardiac tampon and you can see the top right figure, you can see the heart on the left and can you see the space and that space? Normally? It has got nothing. So when you have cardiac tamar, how does Candia tampon not happen any idea? Is it medical or term or? So, medically, you call pleural effusion, uh card uh pericardial effusion, but tampon is blood, effusion is fluid. How do you get blood usually by penetrating trauma? Where would you get the penetrating trauma when you go to suspect. So remember you've got to suspect all this, if you suspect, then only you will go looking for it otherwise you'll miss it. So it's, it's trauma in between in the anterior chest, between the nipple lines and penetrating. So penetrating the knife stab wounds or gunshot or in the back between the scapular borders, any penetrating wound there, thin cardiac Tana and go looking for it. So how would you diagnose cardiac Tana? The book says there's a clinical way but it's, it's rubbish because in a busy er you cannot use that. But just as a thought, any thoughts on how you can, anyone knows that that uh that clinical feature be bex million brilliant musa Bextra. Now that's uh what that's a raise JVP, raise neck veins, that's hypotension and, and, and, and respiratory rate. Uh But you don't do that this day and age. What we use is ultrasound. We use bed cell, ultrasound and diagnose cardiac tamar. If you diagnose it, then you do immediately, you can drain the blood by using what we call pericardiocentesis. There is a special pericardiocentesis, long needle, you go through the inferior part of the um uh you know, in the zi sternum pointing towards the same side, scapula with the, with the cardiac monitoring going on and with the syringe attached. And uh if you know, just to avoid hitting the muscles, ventricular muscle, you drain the blood a 20 mil drainage is enough but you, you leave the cannula in, you leave the cannula in case further collection happens, but that patient needs to go to the cardiac center as well. Ok. Um um I think that's all the re all the causes uh next slide. So those were the life threatening how you would diagnose. Now, I'm, I'm coming towards the end now. Uh something you have to remember the normal uh figures of the arterial blood gas. Um and, and, and you, you look for variation. The, the key things are PP CO2 po two. Now, when you're interpreting po two, remember is the patient on oxygen or not and that's how you're gonna interpret base access is very important for metabolic reasons. A negative base access is a feature of metabolic acidosis. Next slide. Yes, joy focus is, is what we use. Um And this is well score. I can't remember. I look up, look up, look it up when I'm on the treating a patient. Not all the scores are the same. Some are one, some are 1.5 some are three, but those are the risk factors that you got to go through and see, see what the scoring system is before you decide if it's a score of four or more. They say you start the treatment, uh you don't need to do d-dimer. Uh But if it's a score of less than four, you could do a d-dimer and see what the d-dimer shows. Ok. Next slide. Now and, and once you've saved the life of the patient, that's when you go back and you haven't finished because you've got to now take a detailed history which you all know, you know, of the breathlessness and other symptoms. You know, how long it's been going on for? How did it start suddenly in seriously any exacerbating factors? Anything that's making it worse, any associated symptoms like chest pain, short, you know, um sweatiness or hemoptysis or fever or cough, et cetera. Ok. Now remember a cardiac failure, cough, fetches, white fti sputum, um hemoptysis is blood and infective is brown, rusty, even green or yellow. Um Review of other systems don't forget, even though you're dealing with the respiratory system, it can have impact on other systems. So always examine the other systems, cardiovascular gastro and neurological and not forgetting ample history because time is running away. So you take a quick allergic history, medication history, past medical history, et cetera. Next slide. Ok. And this is global holistic history, not forgetting past medical history, drugs, allergies, smoking is very important here. And, and the secondary survey is you've already assessed the lungs. What you left is listen to the heart sounds, assess the abdomen, neurological, not in details, you know, um next slide and, and remember the investigations, you may not have done it at the life threatening stage. But if you haven't done it, then you know, bloods, you might have done it because you've taken the bloods as you put in the cannula. But chest x-ray is a key investigation. We talked about ABG somebody mentioned about ECG you must and CT now, CT is the mainstay of investigation, imaging modality these days for a chest trauma. Uh as and as you heard me from a top that we do a pan CT now from head to pelvis. So, CT chest is part of that CT P is different. Ok. Um Well, remember the patient is pregnant, we can't do a CT P in which case we do AAA um um radio light scan or or so forth or ultrasound. Ok. Next slide and using those uh history examination and further investigation, what you're trying to do is identify uh the potentially life-threatening. Now, if they're, if they're not killing the patient immediately, if you don't diagnose and treat it, they'll kill the patient at some point what we call potentially life-threatening. So again, same, we've, you know, the features of diagnosis are same here. You have time to spend time on investigation and treatment, spontaneous pneumothorax. We talked about COPD exacerbation. These are not lifethreatening, acquired pneumonia, heart failure, now moderate and severe asthma. Uh uh you know, so by treating a life threatening asthma, you can bring it down to moderate and severe asthma, the pulmonary embolus where you're suspecting or a minor pulmonary embolus, even anemia can cause. So, you know, you look at the hemoglobin. You look at the, the, the, the conjunctiva, they are pale for some reason that can cause breathlessness. Simple anxiety can cause breathlessness. What they do is they demonstrate hyperventilation. Yeah. If you do an ABG on that patient who is breathless but hypoventilating because of anxiety, what would you see in ag any thoughts? What'll happen to the CO2 CO2? Wash out? Yes. So CO2 will go down because they are breathing. They CO2 out, ok? And you'll get respiratory alkalosis. Ok? And see a lung can present as acute breathlessness in the terminal stages. Uh They may have already been diagnosed, um, you know, with your history of smoking, et cetera. Um and all you have to do is, you know, whatever symptomatic care that's possible. Next slide please. And we talked about a lot of the drugs. Um, you need the drugs immediately and later on fluids, um only if they are in shock. But remember we have come out, come away from giving massive amounts of fluids in a shock patient that's gone because it dislodges the patient's own clotting mechanism. What we use is, um, is, is hypotensive, resuscitation, balance, resuscitation by giving small amounts of fluids and giving them as a, as a challenge to see whether it's made a difference. So, what you do is you go back and see has the patient responded or have they not responded? You give some more fluids? Ok. We talked about ventilation um, the two types, the invasive noninvasive and the procedures, the two procedures in a breathless patient you might need is needle thoracocentesis and chest pain. That's all you can save the patient. All right, know these two, I, there's no time to take you through. Uh, but it's absolutely important to know it. Ok. The only thing to say is in open pneumothorax or traumatic pneumothorax. We don't use, I personally don't use Seldinger because they are piddly. Um, you know, er, chest drain tubes. I use the tex chest drain without a troch car because when I was junior training, we used to use stro car, a car was a metal tro used to cause injury to viscera, heart lungs, liver, but we don't use Stroker. Now we use tex drain. Uh, you know, depending on the age and structure from 25 to 32. Um, and you connect it to an underwater seal drain and you monitor the blood. Ok. Uh, those are the procedures. So a chest drain and a cannula will save the patient in a chest in a chest trauma or even breathless chest patient. Ok. Um, um, next slide. So. Ok. Um, look at these x-rays. Somebody will tell me one, each one of you top left, what it says collapsed lung. But what's the diagnosis? What's causing the collapse, pneumothorax? Excellent. You can see no air shadow, no bronchovascular markings and the collapsed lung. Top, right. What is it? Top right? Tension could be so tension pneumothorax, you should not see it on an x-ray ideally. Ok. Um, top, right. What do you think there's a shadow in the, um, your right lung, mid zone? What do you think? Who will say well done? Um, Hep Ziba and, ok, pneumonia. It is pneumonia, not query MDE. It is, uh, that severe pneumonia and that's what's called consolidation. If you listen over there with your stethoscope, that's where you hear. Uh bronchial breath sounds lung consolidation. Excellent. Done. Ok. Bottom left. What do you think? It's a CT scan. This is ct, not just ct thorax. What do you think it is p excellent. So if you look at the pulmonary trunk, you can see the filling defects. Uh It's a, it's a subtle embolus. Uh That's a P that's AC TP A. You can see the arrow and last one bottom, right? What do you think that is? It's LVF mucy. Excellent. You can see the cotton will exudates. You can see the upper lobe diversion. That's typical of pulmonary edema. Wonderful ed next slide, please. Ok, a bit. Few more. So top left. What is that? Uh top left. Can you see a complete white out of the right lung trauma history? This is what my No, this is not fibrosis done here. This is acute situation, trauma, chest, massive hemothorax, not just simple, massive hemothorax. That's what it looks like. Ok. The middle picture, the middle picture. What do you think that is, if you look close, you can see the rib fractures. Um, and that's flail chest, you can see and if you see the shadows in the lungs, that's what pulmonary contusion, it's bruising of the lung. That's what it looks like. Ok. Bottom, right. Bottom. Right. What do you think that is bottom, right? Anyone if you have flail chest. Fatima. Good. Tam tampon is the bottom left. Yes. Can you see that? Uh this is your pocus or ultrasound? And you can see the black shadow that's the blood, that's tampon. OK. Got it. Ta Excellent. So thank you very much for that. Um Hoping that was a bit useful. Next slide. OK. So I put this picture up anyone, any anyone wants to say what what this is? If you, you would have seen it before, you don't see it now, but you saw it at some point in this. So this is a picture of what we're nearly there. Who will say this is not OK. This is COVID. This is COVID pneumonitis. You can see the bilateral distribution, you can see the upper lobe involvement. Those are the two key features of, of uh COVID. So this is COVID. Um We used to get um thanks for your comments. This is what we used to get in the COVID peak. Next slide, please. So that's me done. So what we've done is we've discussed what breath breathlessness is. We've looked at medical and traumatic causes. We talked about treatment and we gave you an approach to assess hopefully when you come across your next breathless patient. If you follow this safe approach, you should be able to diagnose and, and treat. I'm not saying you don't need investigation immediately. You may not, but you know, ultrasound is revolutionized because bedside ultrasound takes no time at all. OK? I think that's it. Um um some references I put in um and I'm going to give you two questions. Um Firstly, um I'll, I'll, I'll hear, hear your questions but just listen to this. Um So can I give say this question? Yeah, go ahead. Yeah. Yeah. OK. First question. Uh 40 year old sudden short of breath with chest pain. No, wheeze likely diagnosis. I'll give you some alternatives. Acute asthma pneumonia, pe pneumothorax, COPD, exacerbation. What do you think be? Ok. Most likely diagnosis could be a pneumothorax as well with chest pain? Ok. Next, next scenario. OK. Those you are seeing p good 65 year old smoker with fever, productive cough, local. Wheeze, what is the most probable cause do you think? Uh So I'll give you the again amongst those causes. COPD. Ok. Infective COPD because you can get noninfective COPD, but it could be pneumonia as well. Yeah, it could be pneumonia. Oh, well done. Thank you so much. Brilliant. So, does anyone have any questions after all that? I'm sure everyone's got loads. Yeah. And just so that, you know, if, if you did sign up for last week's, what was last week's toxicology? Was it last week? San Joy? Yeah, if you sign up for that, what we'll do is we've got another date in mind. So what we'll do is I'll just reschedule that event so that you are already registered. If you'd already registered for the previous one that we had to cancel, you will be registered for the next one and I'll let you know. Ok. So does anyone have any questions? So of the dates I've given you, you can spread the topics the way you want to? No, they're only all thanking me but stunned to silence. Hope that was useful. Everyone hope that was useful, please. Any dates for fracture management soon over to you, I will sort them honestly. I'm so sorry that I have the certificate. Yeah, you need to fill out your feedback form and then you'll get your certificate. Ok. And please do. Thank you. Write in other things that maybe Sandra can teach you on. Sandra is loving doing the teaching. So please do if they feel beneficial if they want, I'm there for them and you know, I'm reaching the whole world. That's, you know, that's unbelievable. Unbelievable. How could I get the feedback form? So the feedback form is going to be emailed to you. The feedback form will be in your inbox, it should be there. Now, you got to fill that out. As soon as you've submitted it, then your certificate will be on your med profile. We have a question, how do we not give 100% oxygen to COPD patients? So the way you do is the 100% oxygen, the high flow we give using a, a well fitting mask, reservoir bag and connected to wall oxygen to 50 liters a minute. What you do is when you realize the patient is COPD, you change that to what we call um venturi masks. They are different colored masks that give you X amount of oxygen X percentage or you can use simple mask or nasal cannula and reduce the fio two the the the inspiratory oxygen concentration that you can do it that way as well. Thank you from Russia. Brilliant. Thank you for Malta. Brilliant. So can't hear you. Yeah. Um If there's no more questions, we will say goodbye. Bye bye. Right. So I'm going to, so everyone have a wonderful weekend, right.