Real Time and Real Life

Here’s a video of a real patient in the first few minutes of arrival in emergency.

Information will appear in real time. Each time you are prompted, pause the video and think or write down your best answer.

Working rapidly to narrow down your DDx based on limited information is a key skill for the emergency physician – are you up for the challenge??



  1. awad says:

    1- COPD exacerbation
    2- bronchial asthma exacerbation
    3- bronchiactasis exacerbation

  2. awad says:

    COPD with corpulmonale and AF

  3. awad says:

    2- ABG

  4. awad says:

    Right ventricular hypertrophy and strain

  5. awad says:

    Low flow o2
    Bibap if needed

  6. awad says:

    Stop smoking
    Correct AF

  7. this is a nice method of learning!

  8. Hypertensive Emergency with pulmonary oedema
    Atrial Fibrallation
    Manage with IV GTN

  9. Lakshan says:

    It is Acute Pulmonary Oedema , Prop up, start with CPAP change to BiPAP if indicated in blood gas, IV GTN infusion , ECG , may need enoxaparin also.

  10. Nick Taylor says:

    So this is a severe presentation of HFPEF (vascular failure). The patient is hypertensive tachycardic and hypoxic.

    First question re DDX . You can see the increased work of breathing, rapid respiratory rate but normal I:E ratio. Asthma would have a long expiration time, and PE doesn’t usually have work of breathing because there’s no airflow problem, so it’s pneumonia, ARDS, LVF or restrictive lung disease

    With the extra information of the hypertension, it really only leaves LVF and restrictive lung disease. Severe pneumonia or ARDS is likely to be hypotensive . The Vascular failure variant of LVF is now much more likely given the hypertension.

    Bedside tests are a VBG, ECG and USS.
    The echo shows a thickened LV with relatively preserved ejection fraction and no significant RVH (helping to exclude severe restrictive lung disease , as you’d expect RVH). The lung USS shows widespread bilateral B line profile , consistent with severe acute pulmonary oedema (severe pulmonary fibrosis can give B lines, but they tend to be more “static” in B mode USS.)

    Treatment is CPAP non invasive ventilation with high FiO2 initially, start with PEEP 10 at increase up to 20 if needed. This reduces work of breathing, improves oxygenation, reduces preload (positive intrathoracic pressure) and reduces afterload (postive pressure across myocardial wall). GTN immediately as a sublingual tablet or patch and then as an infusion. No frusemide or morphine .

    To improve this care
    Sit the patient up (helps with fluid redistribution , reduces preload, improves lung mechanics)
    Increase PEEP
    Increase GTN infusion and/or add better arteriolar dilation eg hydrallazine or SNP

    Revascularise (if STEMI)
    Inotropes (if hypotensive)
    Position (Prop up patient)
    Pressure (CPAP)

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