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
The following is part of the CanadiEM Frontline Primer. An introduction to the primer can be found here. To return to the Primer content overview click here.
This post was edited by Dr. Brent Thoma MD FRCPC. This post was copyedited and uploaded by Evan Formosa.