Differential Diagnosis for Possible Chemical Inhalation Injury
Single Most Likely Diagnosis
- Chemical Inhalation Injury: The strong smell of bleach reported by EMS and the patient's symptoms of shortness of breath are highly suggestive of a chemical inhalation injury, likely due to bleach (sodium hypochlorite) exposure. The improvement with albuterol and atrovent also points towards a reactive airway component, which is common in chemical inhalation injuries.
Other Likely Diagnoses
- Asthmatic Exacerbation: Given the patient's history of asthma, an exacerbation could be a contributing factor to her shortness of breath. The response to albuterol and atrovent supports this diagnosis.
- Acute Respiratory Distress Syndrome (ARDS): Although less likely without more severe symptoms or hypoxia, ARDS could be a complication of severe chemical inhalation injury, especially if the patient had a significant exposure.
- Pulmonary Edema: The patient's shortness of breath and initial low oxygen saturation could also be indicative of pulmonary edema, possibly cardiogenic or non-cardiogenic (e.g., due to the inhalation injury).
Do Not Miss Diagnoses
- Cardiac Ischemia or Myocardial Infarction: In a 93-year-old patient, shortness of breath can be a presenting symptom of cardiac ischemia or myocardial infarction. The stress of a chemical inhalation injury could precipitate a cardiac event.
- Pneumonia: Especially chemical pneumonia, which could result from the inhalation of toxic substances. Early recognition and treatment are crucial.
- Anaphylaxis: Although less likely given the context, anaphylaxis could occur in response to certain chemicals and would require immediate recognition and treatment.
Rare Diagnoses
- Methemoglobinemia: Certain chemicals can induce methemoglobinemia, a condition characterized by an abnormal amount of methemoglobin, a form of hemoglobin, in the blood. This would be a rare but potentially life-threatening complication.
- Toxic Epidermal Necrolysis (TEN) or Stevens-Johnson Syndrome (SJS): These are severe skin and mucous membrane disorders that could be triggered by certain chemicals, although they are more commonly associated with medications.
Diagnostic Tests
- Arterial Blood Gas (ABG) to assess oxygenation and ventilation
- Complete Blood Count (CBC) to evaluate for signs of infection or inflammation
- Basic Metabolic Panel (BMP) to assess electrolyte balance and renal function
- Cardiac enzymes (e.g., troponin) to rule out myocardial infarction
- Chest X-ray to evaluate lung fields for signs of injury, edema, or infection
- Pulse Oximetry and continuous oxygen saturation monitoring
- Consider toxicology screen if the chemical involved is suspected to have systemic effects
Treatments in the Emergency Room
- Oxygen Therapy: Continue oxygen as needed to maintain adequate oxygen saturation.
- Bronchodilators: Continue albuterol and ipratropium (Atrovent) as needed for bronchospasm.
- Corticosteroids: Consider administering corticosteroids to reduce inflammation in the airways.
- Cardiac Monitoring: Monitor the patient's cardiac rhythm and consider cardiac enzymes to rule out myocardial infarction.
- Supportive Care: Provide supportive care, including monitoring of vital signs, and be prepared to manage any complications that may arise.
- Decontamination: Ensure the patient has been properly decontaminated to prevent further exposure to the chemical.
- Consultations: Consider consulting with a toxicologist or a pulmonologist for further guidance, especially if the patient's condition does not improve with initial treatment.