14.01.14 A+E thoughts

• Don't confuse a silent chest with recovery in asthma

  • If they're clearly still breathless then give nebs (in preference to inhaler)

  • A marked wheeze may suddenly appear as they recover slightly

• Don't be distracted by the broken bone

  • WHY DID THEY FALL???

• Have an extremely low threshold for investigation in chest pain

  • In the average UK ED one STEMI gets sent home every 6 months

  • Old patients may play down symptoms or have atypical pain

  • Make sure you step back and look at their symptoms objectively

    • c.f. Lady in Croydon: 80, 3 x MI risk factors, chest pain, SOB

Chronotropic incompetence (CI)

• Inability of the heart to increase its rate commensurate with increased activity or demand

• Manifests as reduced variation on 24-hour tape

  • Present in 1/3 of HF patients

• Unusual pneumothorax presentations

  • Delayed presentation, vague symptoms

  • Pain moves around