Rosen & Barkin's 5-Minute Emergency Medicine Consult (228 page)

• Vigilant airway attention
  
• Position of comfort with suction available
  

• Vigilant airway attention
  
• Position of comfort with suction available
  
• NPO
  
• 0.9% NS 500 mL (peds: 20 mL/kg) IV fluid bolus for significant dehydration
  
• Evaluate for life-threatening causes of dysphagia including
  
  • Retropharyngeal hematoma/abscess
    
  • Epiglottitis
    
  • Foreign body
    
  • Upper airway obstruction
    
  • Cardiovascular causes (thoracic aortic aneurysm)
    

• Nitroglycerin for esophageal spasm
  
• Glucagon for impacted foreign body
  
• Treat complications:
  
  • Airway obstruction
    
  • Aspiration, pneumonia, lung abscess
    
  • Dehydration, malnutrition
    
• Endoscopy
  
• Dietary modifications:
  
  • Thickened liquids for neuromuscular disorder
    
  • Thin liquids for mechanical disorders
    

• Glucagon for food impaction: 1 mg IV followed by 2nd dose of 1 mg after 5 min if there is no improvement in symptoms (0.02–0.03 mg/kg in children, not to exceed 0.5 mg):
  
  • Success rates vary from 12–50%, which may not be better than spontaneous passage.
    

Calcium channel blockers and nitrates may be used in motility disorders (e.g., achalasia and nutcracker esophagus)

FOLLOW-UP

• Esophageal obstruction persists despite treatment
  
• Compromised fluid or nutrition status
  
• Inability to protect airway
  
• Unable to tolerate own secretions
  

• Well-hydrated patient
  
• Urgent neurology, otolaryngology, or gastroenterology referral arranged for further evaluation and treatment
  

Next day follow-up with PCP or ENT/GI

• Clear liquid diet prior to ENT follow-up
  
• Return if SOB, chest pain, or unable to tolerate own secretions.
  

• Consider foreign-body aspiration in children presenting with dysphagia.
  
• Dysphagia is a common presentation in stroke.
  
• Consider in patients with recurrent pneumonia.
  
• Assess for life-threatening causes of dysphagia before deferring definitive diagnosis to outpatient setting.
  

• Fass R. Evaluation of dysphagia in adults. Cited from
  UpToDate.com
  . Accessed February 22, 2013.
  
• Furnival RA, Woodward GA. Pain-dysphagia. In: Fleisher GR, Ludwig S, Henretig FM, eds.
  Textbook of Pediatric Emergency Medicine
  . 5th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2006.
  
• Seamens CS, Brywczynski. Esophageal disorders. In:
  Harwood Nuss’ Clinical Practice of Emergency Medicine
  . 5th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2010.
  
• Smith Hammond CA, Goldstein LB. Cough and aspiration of food and liquids due to oral-pharyngeal dysphagia: ACCP evidence-based clinical practice guidelines.
  Chest.
  2006;129:154S–168S.
  
• Yalçin Ş, Ciftci AO, Karnak I, et al. Management of acquired tracheoesophageal fistula with various clinical presentations.
  J Pediatr Surg.
  2011; 46(10):1887–1892.
  

See Also (Topic, Algorithm, Electronic Media Element)

Stroke

CODES

• 787.20 Dysphagia, unspecified
  
• 787.22 Dysphagia, oropharyngeal phase
  
• 787.24 Dysphagia, pharyngoesophageal phase
  

BASICS

Inability to breathe comfortably

• Describes a symptom of many possible underlying diseases
  
• Is different from signs of increased work of breathing
  
• Usually an unconscious activity, dyspnea is the subjective sensation of breathing, from mild discomfort to feelings of suffocation.
  
• Dyspnea comes from the Greek word for “hard breathing.”
  
• Often described as “shortness of breath”
  
• Common presenting complaint seen in 3.5% of ED visits
  
• Caused by difficulties in maintaining homeostasis with respect to gas exchange and acid–base status
  
• Dyspnea usually reflects an impairment in ventilation, perfusion, metabolic function, or CNS drive.
  
• Mechanisms that control breathing:
  
  • Control centers:
    
    • Brainstem and cerebral cortex affect both automatic and voluntary control of breathing.
      
  • Chemo, stretch, and irritant sensors:
    
    • CO
      ₂
      receptors located centrally and PO
      ₂
      receptors located peripherally.
      
    • Mechanoreceptors lie in respiratory muscles and respond to stretch.
      
    • Intrapulmonary mechanoreceptors respond to chemical irritation, engorgement, and stretch.
      
  • Effectors of respiratory center output are in the respiratory muscles and respond to central stimulation to move air in and out of the thoracic cavity.
    
  • Motor–sensory control of the diaphragm and muscles of respiration are controlled by C3–C8 nerves and T1–T12 nerves.
    
• Derangements of any of these neurosensory pathways produces dyspnea:
  
  • Many etiologies for the sensation of dyspnea are due to the complex nature of mechanisms that control breathing.
    

• Upper airway:
  
  • Epiglottitis
    
  • Laryngeal obstruction
    
  • Tracheitis or tracheobronchitis
    
  • Angioedema
    
• Pulmonary:
  
  • Airway mass
    
  • Asthma
    
  • Bronchitis
    
  • Chest wall trauma
    
  • CHF
    
  • Drug-induced conditions (e.g., crack lung, aspirin overdose)
    
  • Effusion
    
  • Emphysema
    
  • Lung cancer
    
  • Metastatic disease
    
  • Pneumonia
    
  • Pneumothorax
    
  • Pulmonary embolism
    
  • Pulmonary HTN
    
  • Restrictive lung disease
    
• Cardiovascular:
  
  • Arrhythmia
    
  • Coronary artery disease
    
  • Intracardiac shunt
    
  • Left ventricular failure
    
  • Myxoma
    
  • Pericardial disease
    
  • Valvular disease
    
• Neuromuscular:
  
  • CNS disorders
    
  • Myopathy and neuropathy
    
  • Phrenic nerve and diaphragmatic disorders
    
  • Spinal cord disorders
    
  • Systemic neuromuscular disorders
    
• Metabolic acidosis:
  
  • Sepsis
    
  • DKA
    
  • AKA
    
  • Renal failure
    
  • Profound thiamine deficiency
    
• Toxic:
  
  • Methemoglobinemia
    
  • Salicylate poisoning
    
  • Cellular asphyxiants:
    
    • Carbon monoxide
      
    • Cyanide
      
    • Hydrogen sulfide
      
    • Sodium azide
      
  • Toxic alcohols
    
• Abdominal compression:
  
  • Ascites
    
  • Pregnancy
    
  • Massive obesity
    
• Psychogenic:
  
  • Hyperventilation
    
  • Anxiety
    
• Other:
  
  • Altitude
    
  • Anaphylaxis
    
  • Anemia
    

• Most common diagnoses in elderly patients presenting to the ED with dyspnea:
  
  • Decompensated heart failure
    
  • Pneumonia
    
  • COPD
    
  • Pulmonary embolism
    
  • Asthma
    

• Common conditions in differential diagnosis for age <2 yr:
  
  • Asthma
    
  • Croup
    
  • Congenital anomalies of the airway
    
  • Congenital heart disease
    
  • Foreign-body aspiration
    
  • Nasopharyngeal obstruction
    
  • Shock
    

DIAGNOSIS