Sudden breathlessness and faintness in a 36-year-old: an emergency case to work up

Why sudden breathlessness with faintness matters

When a young adult is suddenly struggling to breathe and feels faint, the cause is often found in the first minutes from the examination: the chest, the neck, the skin and the pulse. Treat what you find as you go, and get monitoring and an ECG on early.

What to ask in the history

• When it started and what he was doing
• Chest pain: sharp and worse on breathing, or central and heavy
• Cough, wheeze, coughing up blood
• Anything new: food, a medicine, an insect sting; a rash or swelling of the lips or face
• Previous episodes, asthma, allergies
• Smoking and drug use
• Recent immobility, travel, surgery, a swollen leg
• Palpitations; any injury

Red flags

• Unable to speak in sentences
• Low oxygen saturation
• Low blood pressure or fainting
• Breath sounds absent on one side, or the trachea pushed to one side
• Swelling of the lips or tongue, noisy breathing in, a widespread rash
• A quiet chest despite hard work of breathing
• A very fast or irregular pulse; raised neck veins

What to examine

• Airway, breathing, circulation, disability, exposure
• Breathing rate and saturation
• Trachea, chest expansion, percussion, breath sounds, wheeze or stridor
• Skin: rash, hives, swelling
• Pulse, rhythm, blood pressure
• Neck veins, heart sounds
• The legs

First investigations

• Continuous monitoring
• ECG
• Blood gas
• Chest X-ray, without delaying treatment the examination already calls for
• Bedside ultrasound of the lungs and heart
• Troponin; D-dimer only if a clot is judged unlikely
• Mast cell tryptase if anaphylaxis is suspected
• Full blood count, electrolytes

Differential diagnosis of sudden breathlessness with faintness

Grouped, not ranked. Which one fits this patient is for you to work out in the case.

Common mistakes

• Waiting for an X-ray before treating a tension pneumothorax found on examination.
• Ruling out anaphylaxis because there is no rash: the skin can be clear.
• Calling it panic before the physical causes are excluded.