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EM Rotation 2018 > Pulmonology > Flashcards

Pulmonology Flashcards

1
Q

How does a spontaneous pneumothorax develop into a tension pneumothorax?

A

If air can enter the pleural space during inspiration but not escape during expiration

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2
Q

Explain the pathophysiology of a spontaneous pneumothorax?

A

The rupture of a subpleural bleb resulting in free communication of air between the atmosphere and pleural space. As air rushes into the plaural space, and the lung collapses.

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3
Q

What is the result of lung collapse?

A

Results in ventilation-perfusion mismatch as blood flows past the unventilated lung

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4
Q

What is the consequence of an increasing pneumothorax?

A

As the pneumothorax increases, so does the degree of hypoxia

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5
Q

Classically, how will a pneumothorax clinically present?

A
  • With an acute onset of dyspnea and ipsilateral pleuritic chest pain
  • The pain is described as sharp and stabbing and often worsens with inspiration
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6
Q

A patient presents with tachypnea, tachycardia,and hypotention. Upon PE there are decreased breath sounds localized to the right side. The patent is also experiencing an elevated jugular venous pressure. What would you expect the X ray to reveal?

A
  • tracheal deviation away from the pneumothorax
  • hyperlucency
  • lack of pulmonary vascular markings at the lung periphery

(tension pneumothorax)

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7
Q

A patient presents with tachypnea, tachycardia,and hypotention. Upon PE there are decreased breath sounds localized to the right side. The patent is also experiencing an elevated jugular venous pressure. What is the next step in evaluating this patient?

A

Chest Radiograph

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8
Q

If a chest x ray does not show a highly suspected pneumothorax, what is an alternate diagnostic study? And explain why this method is helpful?

A

Expiratory films

-during expiration, the air in the pleural space cannot be exhaled; thus the affected hemithorax cannot decrease in volume to the same degree as the normal lung

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9
Q

What is the treatment for a < 15% volume pneumothorax?

A

Conservative: observation and supplemental oxygen

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10
Q

At what rate is the pleura reabsorbed when treating a pneumothorax?

A

at a rate of 2% per day

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11
Q

What is the treatment for a > 15% volume pneumothorax?

A

Needle or tube thoracostomy `

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12
Q

What is the treatment for a tension pneumothorax?

A

-Needle decompression (even before the chest x-rays are taken)

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13
Q

What is the procedure for a needle decompression?

A
  • Inserting a 14 gauge IV catheter into the pleural space at the level of the 2nd intercostal space, midclavicular line
  • This is followed promptly by a tube thoracostomy
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14
Q

What are the 3 major contributing factors leading to deep venous thromboembolism known as Virchow triad?

A
  1. Venous stasis
  2. Vessel injury
  3. Hypercoagulable states
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15
Q

Congestive heart failure is an example of which of the following?

A. Venous stasis
B. Vessel Injury
C. Hypercoagulable state

A

A. venous stasis

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16
Q

Malignancy, deficiency of antithrombin III, protein C, or protein S, nephrotic syndrome and ulcerative colitis are all examples of which of the following?

A. Venous stasis
B. Vessel Injury
C. Hypercoagulable state

A

C. Hypercoagulable state

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17
Q

Vasculitis, central lines, and previous hx of DVT are examples of which of the following?

A. Venous stasis
B. Vessel Injury
C. Hypercoagulable state

A

B. Vessel Injury

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18
Q

Increased estrogen, antiphospholipid antibodies and sepsis are all examples of which of the following?

A. Venous stasis
B. Vessel Injury
C. Hypercoagulable state

A

C. Hypercoagulable state

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19
Q

A patient is having pain behind the knee on forceful dorsiflexion of foot–what is this sign called? And what is this indicative of?

A
  • Homans sign

- Indicative of DVT

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20
Q

A patient is presenting with unilateral edema 3cm circumfrential difference in extremity. Is this significant?

A

Yes. Anything greater than > 1.5 is significant.

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21
Q

A patient is presenting with unilateral edema that is 2 cm of circumfrential difference, pain in the extremity, and eliciting Homans sign. What is the next step in evaluating this patient?

A

-Duplex U/S

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22
Q

A patient is presenting with unilateral edema that is 2 cm of circumfrential difference, pain in the extremity, and eliciting Homans sign. What is the gold standard in evaluating this patients suspected diagnosis?

A

Venography

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23
Q

A patient is presenting with unilateral edema that is 2 cm of circumfrential difference, pain in the extremity, and eliciting Homans sign. What laboratory studies are a part of the workup for this suspected diagnosis?

A

CBC, PT, PTT

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24
Q

A patient is suspected of having a pulmonary embolism. What would you expect their V/Q scan to be?

A. Normal
B. Low
C. High

A

C. High V/Q

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25
Q

Which of the following is not a side effect to Corticosteroids?

A. DM 
B. HIV
C. Renal failure 
D. Edema 
E. Osteoporosis
F. Growth delays 
G. HTN
A

G. HTN

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26
Q

Which anticholinergic has been known to cause BPH in men treated with asthma?

A

Ipratroprium (Atrovent)

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27
Q

A patient is administered Prednisolone and wants to know how long it will take to “work”. What do you tell this patient?

A

4-8 HRS (for both oral and IV)

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28
Q

What is the benefit of corticosteroids in asthma patients?

A

Steroids decrease relapse and reverse the late pathophysiology

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29
Q

Which asthma medication is most useful in the first hour?

A

Ipratropium (Atrovent)

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30
Q

Which medication can you give for a patient for exercise-induced asthma prophylaxis? Explain how this medication works.

A

Cromolyn; Nedocromil

Mast-cell modifiers: inhibits acute phase response; inhibits mast cell & leukotriene-mediated degranulation

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31
Q

What is the drug of choice for long-term, persistent chronic asthma? What is a side effect of this drug of choice?

A

Beclomethasone (Beclovent)
Flunisolide (Aerobid)
Triamcinolone (Azamacort)

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32
Q

What is the 1st line of tx for an asthma exacerbation? What is the method of administration of this drug?

A 
B2 agonist: 
Albuterol (Proventil)
Levalbuterol (Xopenex) 
Terbutaline (Brethine) 
Epinephrine*
  1. Metered Dose Inhaler
  2. Nebulizer (most commonly used in the ED)***
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33
Q

What is the onset of the Emergency tx for an asthma exacerbation?

A

2-5 minutes *SA B2 agonists

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34
Q

What is the tx for acute bronchiolitis?

A

Supportive: humidified O2 + acetomenophen/ibuprofen for fever; mechanical ventilation if severe

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35
Q

A patient with acute bronchiolitis is having refractory respiratory distress. Albuterol does not seem to be effective. What is the next step in managing this patient?

A

Nebulized racemic epinephrine

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36
Q

In a patient with acute bronchiolitis, when is it appropriate to give corticosteroids?

A

If the patient has hx of underlying reactive airway disease

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37
Q

In an immunocompromised with acute bronchiolitis, what tx is sometimes used in addition to the humidified O2?

A

Ribavarin (also used for Hep C)

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38
Q

For high-risk patients, what is an appropriate prophylactic that can be used?

A

Palivuzumab

hand-washing is preventative

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39
Q

How is RSV transmitted?

A

Transmitted via direct contact with secretions and self inoculation by contaminated hands

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40
Q

Why should you be careful in prescribing Azithromycin for Pertussis in infants <1 month?

A

Because it increases risk for pyloric stenosis

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41
Q

If a patient diagnosed with Pertussis is allergic to macrolides, what should be prescribed instead?

A

Trimethoprim-Sulfamethoxazole (Bactrim)

42
Q

What are complications to Pertussis you should educate your patient on?

A
  1. PNEUMONIA
  2. Encephalopathy
  3. Otitis media
  4. Sinusitis
  5. Seizures
  6. Increases mortality in infants due to apnea/cerebral hypoxia associated with coughing fits
43
Q

What gram stain is Bordetella pertussis?

A

Gram NEGATIVE coccobacillus

44
Q

What is bronchitis?

A

Inflammation of the bronchi and trachea (conducting airways)

Often follows an URI

45
Q

What is the etiology of acute bronchitis?

A

most often a VIRUS: ADENOVIRUS

Bacterial: S. pneumo, Hflu, Mcat, mycoplasma

46
Q

How will a patient with acute bronchitis clinically present?

A

Hallmark is cough* (+/- productive; 1-3 wks)

47
Q

How do you accurately diagnose a patient with acute bronchitis?

A

Clinical diagnosis

CXR is usually normal or nonspecific

48
Q

What is the appropriate tx for acute bronchitis?

A

Symptomatic tx: fluids, rest, +/- bronchodilators; ANTI-TUSSIVES ONLY FOR ADULTS

ABX USUALLY NOT NECESSARY UNLESS COUGHING FOR >7-10 DAYS (or immunocompromised)

49
Q

If a patient has inflammation of the epiglottitis, what is this called and how was the diagnosis likely made?

A

Epiglottitis

Dx made via laryngoscopy (definitive diagnosis but may cause spasm)

OR

lateral cervical CXR: thumbprint sign

50
Q

To prevent further injuring children with a tongue depressor, clinically how do you recognize epiglottitis?

A

3 Ds: Dysphagia, Drooling, and Distress

Fever, odynophagia, INSPIRATORY STRIDOR, dyspnea, hoarseness, muffled voice, TRIPODING

51
Q

What age group is at high risk for epiglottitis?

A

3 months-6 years
2 x MC in males*
DM is a risk factor for adults
Occurs in any season

52
Q

What is the etiology of epiglottitis?

A

H. influenza type B (HiB)–reduced incidence due to vaccination; other causes: S. pneumo, S. aureus, GABHS (S. pyrogenes)

Non-Hib is more commonly seen in adults, esp crack/cocaine use

53
Q

45 y/o male with a hx of cocaine use is admitted for dyspnea. On PE, you notice drooling, hoarseness, inspiratory stridor, and he is leaning forward with his elbows on his lap. What is the best management for this patient?

A

Maintain his airway & supportive tx

  • Dexamethasone to reduce airway edema
  • Tracheal intubation to protect the airway in severe cases
  • Abx: 3rd gen Ceph: Ceftriaxone (Rocephin; IM or IV) or Cefotaxime (Claforan; IV) / +/- PCN/AMP or Anti-staph
54
Q

Parainfluenza virus most commonly causes which respiratory infection?

A

Croup (Larynotracheitis)

55
Q

A 5 y/o male presents to the ED with his parents for a cough. During the PE, you note inspiratory and expiratory stridor. The patient is also hoarse and experiencing dyspnea and has a fever. You note a “barking” seal-like cough. What is the next best step in evaluating this patient?

A

Frontal cervical x-ray: Steeple sign –subglottic narrowing of trachea

56
Q

A 5 y/o male presents to the ED with his parents for a cough. During the PE, you note inspiratory and expiratory stridor at rest with marked retractions. The patient is also hoarse and experiencing dyspnea and has a fever. You note a “barking” a seal-like cough. What is the management of this patient?

A

SEVERE: Dexamethasone + nebulized epinephrine & hospitalization

57
Q

A 5 y/o male presents to the ED with his parents for a cough. During the PE, you note inspiratory and expiratory stridor at rest with mild-moderate retractions. The patient is also hoarse and experiencing dyspnea and has a fever. You note a “barking” a seal-like cough. What is the management of this patient?

A

MODERATE: Dexamethasone PO or IM + supportive tx +/- nebulized epinephrine

Should be observed for 3-4 hours after clinical intervention; if improved, may be discharged home

58
Q

A 5 y/o male presents to the ED with his parents for a cough. During the PE, you note inspiratory and expiratory stridor only when breathing deep with no retractions. The patient is also hoarse and experiencing dyspnea and has a fever. You note a “barking” a seal-like cough. What is the management of this patient?

A

MILD: Cool humidified air mist + hydration; Dexamethasone provides significant relief as early as 6 HRS after a single dose (oral or IM)

+ supplemental O2 in pts with O2 sat <92%
Pts can be discharged home

59
Q

Which of the following is not a risk factor to RSV?

A. Born <35 wks gestation
B. Secondhand smoke
C. Patients with Down syndrome
D. Institutionalized older adults 
E. HTN
A

E. HTN

60
Q

What is the incubation period for RSV?

A

usually 4-6 days

*RSV can survive several hours on the hands

61
Q

What is Tietze syndrome?

A

Costochondritis with localized palpable edema

MC effects the 2nd and 3rd Costochondral junctions

62
Q

What is the most common cause of transudative pleural effusion?

A
  1. CHF

Other etiologies: Nephrotic syndrome, Cirrhosis

63
Q

What 2 factors contribute to creating a transudative pleural effusion?

A

Increased hydrostatic pressure

Decreased Oncotic pressure

64
Q

How does an exudative pleural effusion occur?

A

Occurs when local factors increase vascular permeabilyt (infx or inflammation)

65
Q

A patient is complaining of dyspnea, and pleuritic chest pain. On PE, you notice dullness to percussion on his left lung and there is a decreased tactile fremitus along with decreased breath sounds. CXR reveals blunting of the costophrenic angles (+ menisci sign). You suspect a pleural effusion. What is the test of choice to diagnose this patient?

A

Thoracentesis: send pleural fluid for chemistries and culture

66
Q

A patient is complaining of dyspnea, and pleuritic chest pain. On PE, you notice dullness to percussion on his left lung and there is a decreased tactile fremitus along with decreased breath sounds. CXR reveals blunting of the costophrenic angles (+ menisci sign). Thoracentesis results reveal:

serum protein is 0.6
serum LDH 0.9

What is your diagnosis based on this information?

A

Exudative pleural effusion

Using Lights Criteria exclusive to exudates:
serum protein >0.5
serum LHD >0.6 OR
Pleural fluid LDH > 2/3 upper limit of normal LDH
Presence of ANY 1 = Exudative

67
Q

At what volume should you stop removing fluid from a pleural effusion?

A

Don’t remove >1.5L during one procedure

68
Q

A patient is complaining of dyspnea, and pleuritic chest pain. On PE, you notice dullness to percussion on his left lung and there is a decreased tactile fremitus along with decreased breath sounds. CXR reveals blunting of the costophrenic angles (+ menisci sign). Thoracentesis results reveal:

serum protein is 0.6
serum LDH 0.9
Pleural fluid pH < 7.2
glucose <40 mg/dL
 \+ gram stain

Based on this information, what is the most likely diagnosis?

A

Exudative/EMPYEMA Pleural Effusion

69
Q

A patient is complaining of dyspnea, and pleuritic chest pain. On PE, you notice dullness to percussion on his left lung and there is a decreased tactile fremitus along with decreased breath sounds. CXR reveals blunting of the costophrenic angles (+ menisci sign). Thoracentesis results reveal:

serum protein is 0.6 
serum LDH 0.9. 
Pleural fluid pH < 7.2
glucose <40 mg/dL
 \+ gram stain
What can you use to facilitate drainage of this Empyema?
A

Streptokinase

70
Q

What are options to use for a pleurodesis?

A
  1. Talc* MC
  2. Doxycycline
  3. Minocycline
    * Bleomycin is not used due to toxicity*
71
Q

Why would a pleurodesis be indicated?

A

If there is a malignant or chronic pleural effusion

72
Q

What type of pneumothorax occurs during menstruation?

A

Catamenial PTX: Ectopic endometrial tissue in the pleura

73
Q

What is a pulmonary embolism?

A

A thrombus in the pulmonary artery or its branches

Not a disease but a complication from a DVT*

74
Q

What is the most common SIGN for a Pulmonary Embolism?

A

Tachypnea

75
Q

What is the most common SYMPTOM for a Pulmonary Embolism?

A

Dyspnea

76
Q

What is the classic presentation for a patient with a Pulmonary embolism?

A

***May be asymptomatic, but Classic triad:

  1. Dyspnea
  2. Pleuritic chest pain
  3. Hemoptysis
77
Q

What is the most common predisposing condition for a pulmonary embolism?

A

Factor V Leiden

78
Q

What is the best initial test for a Pulmonary embolism?

A

Helical CT

+ if intraluminal defect is seen

79
Q

What is the gold standard for diagnosing a pulmonary embolism?

A

Pulmonary Angiography: ordered if high suspicion and negative CT or VQ scan

80
Q

A patient’s O2 saturation is <88%; the patient is complaining of pleuritic chest pain is tachypnic and tachycardic. Chest radiographs were normal. What is your thought?

A

A normal CXR in the setting of hypoxia is highly suspicious of a Pulmonary embolism!

81
Q

When a pulmonary embolism does present on a CXR, what can be seen?

A
  1. Westermark’s sign: avascular markings distal to the area of the embolus
  2. Hamptons Hump: wedge-shaped infiltrate (represents infarction)
82
Q

What ABG result is indicative of pulmonary embolism?

A

Initially respiratory alkalosis* (2ndary to hyperventilation) then respiratory acidosis may occur with time

83
Q

How do you manage pulmonary embolism in a hemodynamically stable patient with no contraindications to anticoagulation?

A

2 options:

  1. LMWH
  2. Unfractioned heparin
84
Q

How do you manage a pulmonary embolism in a hemodynamically stable patient with contraindications to anticoagulation or perhaps the anticoagulation was unsuccessful?

A

IVC filter

85
Q

How do you manage a massive pulmonary embolism in a hemodynamically unstable patient?

A

Thrombolytics:

  1. Streptokinase
  2. Urokinase
  3. Alteplase
86
Q

How do you manage a massive pulmonary embolism in a hemodynamically unstable patient who is unable to receive thromolytics?

A

Thrombectomy / Embolectomy

87
Q

When treating PE: What is the antidote for LMWH?

A

Protamine sulfate

88
Q

When treating PE: What is the MOA of LMWH?

A

Potentiates Anti-thrombin III

-works more on factor Xa than thrombin (Factor IIa)

89
Q

When treating PE: What are the CI to administering LMWH?

A 
Renal failure (Cr >2,0) 
Thromocytopenia
90
Q

When treating PE: What is the MOA of Unfractioned Heparin?

A

Potentiates anti-thrombin III, inhibits thrombin (Factor IIa) and other coagulation factors

91
Q

When treating PE: What can occur when you accidentally manage HIT with Warfarin?

A

Pt may develop necrosis–use other anti-coagulants such as:

  1. Argatroban
  2. Bivalirudin
92
Q

Which anticoagulation drug inhibits Vitamin K dependent coagulation factors (2,7,9,10) along with protein C & S?

This medication should be overlapped with heparin for at least 5 days when treating a pulmonary embolism. What is the goal INR?

A

Warfarin (Coumadin)

INR: 2-3

93
Q

When treating PE: What are the CI to a thrombolysis? (Streptokinase)

A
  1. CVA w/in 2 months
  2. Internal bleed w/in 2 months
    * Relative:
    - uncontrolled HTN
    - Surgery/trauma w/in 6 wks
94
Q

When treating PE: Which Novel oral anticoagulant is a direct thrombin inhibitor?

A

Dabigatran

95
Q

When treating PE: What are other Novel oral anticoagulants that can be used instead of Warfarin for at least 3 months after IV UFH or SQ LMWH?

A

Factor Xa inhibitors:

  1. Rivaroxaban
  2. Edoxaban
  3. Apixaban
96
Q

What EKG finding is specific for Pulmonary embolism?

A

S1Q3T3
Deep S in lead I
Pathologic Q wave in lead III
T inversion in lead III

*this is due to the presence of cor pulmonale with a large PE

97
Q

What is the PERC criteria?

A

Age < 50
Pulse <100
O2 sat: >95%

No prior PE* 
No recent trauma or surgery
No hemoptysis 
No use of exogenous estrogen
No unilateral leg swelling
98
Q

Which of the following is not a risk factor to a foreign body aspiration?

A. Dementia 
B. Altered mental status 
C. Alcoholism
D. PUD
E. Impaired cough/swallowing reflex
A

D. PUD

99
Q

For a suspected foreign body aspiration, what can be used for the diagnosis and treatment?

A

Bronchoscopy

100
Q

T or F: Gastric aspiration may cause ARDS.

A

True

101
Q

What side is a foreign body more commonly aspirated?

A

Right side: wider more vertical, shorter bronchus

102
Q

Where would the foreign body’s location be in reference to position:

A. Supine
B. Sitting/Standing
C. Lying on the right side

A

A. Superior segment of the right lower lobe

B. Posterobasal segment of the right lower lobe

C. Right middle lobe or posterior segment of the right upper lobe

EM Rotation 2018 (7 decks)

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