Emergency Medicine

BREATHLESS PATIENT

General Medical Emergencies 75

(ii) Alternatively use a small standard size 16–22 French gauge drain

directed apically for a simple pneumothorax, or a larger 28–32

French gauge directed posterior basally for a haemothorax.

(iii) Admit under the care of the medical team.

Pulmonary embolus

See page 51.

Pulmonary oedema

DIAGNOSIS

1 Pulmonary oedema is usually caused by left ventricular failure due to
myocardial infarction, hypertension, an arrhythmia, valvular disease,
myocarditis or f luid overload.

2 Occasional non-cardiogenic causes include septicaemia, uraemia, head
injury, intracranial haemorrhage, near drowning, and inhalation of smoke
or noxious gases.

3 The onset may be precipitate with breathlessness, cough, orthopnoea, par-
oxysmal nocturnal dyspnoea (PND) and dyspnoea at rest.

4 The patient is clammy, distressed and prefers to sit upright. Look for wheeze,
tachypnoea sometimes with pink froth, tachycardia, basal crepitations and a
triple rhythm or gallop.

5 Establish venous access and send blood for FBC, ELFTs and cardiac bio-
markers, although they do not inf luence the initial management. Attach a
cardiac monitor and pulse oximeter to the patient.

6 Perform an ECG to look for acute ischaemia, arrhythmias and evidence of
underlying cardiac disease.

7 Request a CXR that shows engorged upper-lobe veins, a perihilar ‘bat’s wing’
haze, cardiomegaly, septal Kerley B lines, and small bilateral pleural
effusions.

MANAGEMENT

1 Sit the patient upright and give 40–60% oxygen, unless the patient is known
to have chronic bronchitis, in which case 28% oxygen should be used. Aim
for an oxygen saturation above 94%.

2 Give GTN 150–300 g sublingually, which may be repeated. Remove the
tablet if excessive hypotension (systolic BP <100 mmHg) occurs.

3 Give frusemide (furosemide) 40 mg i.v., or twice their usual oral daily dose
i.v. if already on frusemide (furosemide).

4 Get senior ED doctor help in refractory cases, repeat the frusemide (furo-
semide), and commence a GTN infusion, provided the patient is not hypotensive.