Can’t Miss Diagnoses
- COVID-19 or other Viral Illnesses (Obviously)
- Pneumonia (PNA)
- Congestive Heart Failure (CHF)
- Acute Coronary Syndrome (ACS)
- Acute exacerbation of Asthma
- Acute Exacerbation of Chronic Obstructive Pulmonary Disease (COPD)
- Pulmonary Embolism (PE)
- Aortic Dissection
- Pneumothorax (PTx)
- Cardiac Tamponade
Mimics due to high respiratory rate
- Diabetic Ketoacidosis
Points to focus upon
- Previous Seasonality / Patterns – to differentiate asthma from COVID-19, etc.
- Allergies or new allergic reaction precipitants (soaps, perfumes)
- Medication history and adherence; inhalers, diuretics
- Pulmonary Embolism risk factors (use PERC and Wells Criteria)
- CAD risk factors (also compare new and old ECGs)
- Has the patient used their multidose inhaler (MDI) with SPACER? (This is a common reason for Salbutamol “not working”)
- Functional Status – Exercise Tolerance, Recent Decline?
- Changes in diet – especially with CHF patients (Higher salt intake?)
- Use of Medications – Nitro Spray effective? Adherent to anticoagulant prescriptions?
- Always check for signs of DVT on your physical exam
- LOOK FOR SIGNS OF ANAPHYLAXIS (swelling, hives, etc.)
- Chest x-ray
- CBC, BUN, Cr, Lytes, Glucose, VBG +/- Lactate
- Serial Troponin where warranted
- Consider ECG – Remember to compare an old ECG
- Consider D-Dimer
- Consider telemetry
Tips on Tests
hs-troponin T – the 2h delta to rule-out is <4ng/L and the delta to rule-in is >= 10ng/L. ( EM CASES)
Remember – don’t be purely fooled by an elevated troponin – COVID-19 is known to cause MYOCARDITIS in patients (which can lead to a troponin elevation), read more here.
CXR – looking for alternative diagnoses (Pneumothorax, pneumonia) or incidental findings (ground-glass opacities, suggestive of COVID-19)
BE CAREFUL. ALWAYS USE APPROPRIATE PPE WITH DYSPNEIC PATIENTS (remember, COVID-19).
Be careful NOT to fully anchor on the diagnosis of COVID-19 related viral illness, however, remember that early research shows that COVID-19 is probably pro-inflammatory and creates a hyper-coagulable state. VTE may be more prevalent in this population.
Always consider that your patient may have more than one diagnosis too.
Recommended reading, videos, and podcasts
- CRACKCast E025 – Dyspnea Overview
- COVID-19 related assessment and Recommendations
- CRACKCast E074 – COPD
- CRACKCast E073 – Asthma
- EMCases – Pulmonary Embolism; Here and Here