Airway & Respiratory Emergencies Flashcards Preview

Q4 EM Surg > Airway & Respiratory Emergencies > Flashcards

Flashcards in Airway & Respiratory Emergencies Deck (71):
1

2 types of airway obstruction & outcomes

partial or complete

partial often->complete if not cleared

complete->respiratory arrest if not cleared

4 mins from complete obstruction to brain damage
(U) in pre-hospital setting

2

Types of airways

oral airways
nasal
laryngeal mask

3

Foreign body aspiration in a Toddler sxs

-persistent cough, unilateral wheezing
-NO URI sxs (can be tough)
-↓breath sounds
-often not seen on CXR
-post-obstructive atelectasis, pneumonia
-not always down right mainstem

4

Emergency Room at Trauma Center

LeForte fractures
Basilar skull fractures

5

Burn Center

Airway edema

6

Anaphylaxis & Acute Allergic Rxns

Severe hypersensitivity rxn w/ CV collapse & resp comp

7

Anaphylaxis & Acute Allergic Rxns: Pathophysiology

-Antigen-antibody binds to mast cells
-IgE mediated histamine release
-increased vascular permeability, vasodilation, bronchial constriction
-increased mucous gland secretion

8

Anaphylaxis & Acute Allergic Rxns: (C) causes (4)

-Antibiotics
-ASA & NSAIDs
-shellfish, nuts, eggs, milk
-hymenopytera stings

9

Anaphylaxis & Acute Allergic Rxns: clinical features (6)

onset: secs to hrs
angioedema
tightening in throat/chest
laryngeal swelling & bronchial spasm, hoarseness, stridor, wheezing
respiratory distress & apnea

10

Anaphylaxis & Acute Allergic Rxns: Dx

clinical
check airway, BP, SaO2, lungs immediately

11

Dx of anaphylaxis & Acute Allergic Rxns

clinical
check airway, BP, SaO2, lungs immediately

12

Anaphylaxis & Acute Allergic Rxns: Tx (8)

1- airway management
2- oxygen
3- antihistamines:
H1 (diphenhydramine or hydroxyzine), H2 (cimetidine)
4- Beta2 agonists (albuterol)
5- steroids (methylprednisolone)
6- endotracheal intubation
7- surgical airway
8- If hypoTN: IV bolus and epi

13

Angioedema

(S) to urticaria but w/
LARGER EDEMATOUS AREAS,
INVOLVE BOTH DERMIS & SUBCUTANEOUS,
frequently involving the head & neck

14

Causes of angioedema (3)

-hereditary or acquired
-insufficient synthesis of C1esterase inhibitor (rare, autosomal dominant)
-ACE inhibitors

15

Tx of angioedema (5)

Airway management
Supportive
Plasma concentrate of C1 esterase inhibitor
Epinepherine, antihistamines, steroids
Danazol:↑synthesis of C1 esterase inhibitor

16

Retropharyngeal Abscess: definition

-a localized collection of pus in the retropharyngeal space
-rare

17

Retropharyngeal Abscess: caused by (4)

-mixed gram negative & anaerobic bacteria
-tonsillitis
-otitis media
-pharyngeal trauma

18

Retropharyngeal Abscess: signs & symptoms (9)

"FOND M CATS"
Fever
Odynophagia
Neck swelling
Drooling
Meningismus
Cervical adenopathy
Airway obstruction
Torticollis
Stridor

19

Retropharyngeal Abscess: dx

clinical
soft tissue lateral neck x-rays (gas, mass)
CT Neck

20

Retropharyngeal Abscess: tx (4)

Airway Management
Antibiotics
Admission
Surgical Drainage

21

Epiglottitis

infection of the supraglottic structures including the epiglottis, lingual tonsillar area, epiglottic folds & false vocal cords

22

Epiglottitis epidemiology

age 2-7 before H. influenza B vaccine
stem occasionally in adults
HiB, Strep, Staph (not 100% protected by vaccine)
rare

23

Signs and Sxs of Epiglottitis

abrupt onset over several hours
fever
stridor
toxic appearance
dysphagia
odynophagia (painful swallowing)
drooling
tripod position
altered LOC
cyanosis
airway obstruction

24

Epiglottitis dx

-best if done clinically due to the tenuous airway
NEVER stick a tongue blade in throat
-soft tissue lateral neck x-ray if very stable

25

Epiglottitis tx

IMMEDIATE attention to control the airway
-Antibiotics once airway is secured
3rd generation cephalosporin

26

Croup (Laryngotracheobronchitis) description & usual cause

(U) benign, self limited inflammatory condition of the trachea below the level of the vocal cords (subglottic),

(U) caused by parainfluenza virus

27

Croup (Laryngotracheobronchitis) epidemiology

age range 6 months to 3 years
can see as old as 15 years
increased in winter

28

Croup (Laryngotracheobronchitis) signs and sxs

2-3 day history of URI
low grade fever
gradual worsening "barking seal" cough, especially at night
stridor
dyspnea
retractions
tachypnea

29

Croup (Laryngotracheobronchitis) Diagnosis

Clinical
PA CXR shows "STEEPLE SIGN" (but not very sensitive or specific)

30

Croup (Laryngotracheobronchitis) treatment

airway management
cool mist
oxygen if needed
nebulized epinephrine (must observe for 3-4 hours after tx)
steroids: prednisolone 1mg/kg
dexamethasone (Decadron) .15 to .6 mg/kg IM or PO (max 10 mg), lasts up to 56 hrs

31

Whooping Cough: cause, prevention, high risk groups

a respiratory emergency
(C): Bordetella pertussis, a gram negative aerobe
cycles every 4 to 5 years
vaccine (DPT) does not give complete protection after about 10 years
-unvaccinated infants & toddlers at highest risk

32

Whooping Cough: signs and symptoms

URI sxs in early stage
fever usually absent
paroxysms of coughing in later stage
inspiratory stridor in younger patients
post-tussive vomiting

33

Whooping Cough diagnosis, transmission, risks, tx

-by nasopharyngeal swab on special culture media
-highly contagious in early stage
-risk of SIDS & airway compromise in unvaccinated kids
-need to pretreat unprotected contacts (Erythromycin/Azithromycin)

34

Bronchiolitis (RSV) def

clinical syndrome in infancy characterized by rapid respiration, chest retractions & wheezing

35

Bronchiolitis (RSV) epidemiology

Winter
Male>female
0-2 years range (peak 2-6 months)
Respiratory Syncital Virus (RSV): most common cause

36

Bronchiolitis (RSV) pathophysiology

bronchiolar obstruction from submucosal edema & mucous plugging

37

Bronchiolitis (RSV) signs & sxs

runny nose, sneezing
low grade fever
dyspnea
tachypnea
intercostal retractions
wheezing
cyanosis
apnea

38

Bronchiolitis (RSV) diagnosis

-clinical
-CXR-hyperinflated lungs
pulse oximetry usually shows hypoxia
-viral cultures/fluorescent -monoclonal antibody testing of NP swabs

39

Bronchiolitis (RSV) treatment

Airway management, primarily supportive
Mild cases [alert, playful, feeding well, RR<50, no retractions, no hypoxia, w/no associated significant illness] can be observed at home,
All others should be admitted
Oxygen
Beta 2 agonists
Ribavirin for severely ill or intubated

NO steroids

40

Asthma definition

a condition characterized by paroxysmal attacks of reversible bronchospasm, mucous pluggint and inflammation of the tracheobronchial tree

41

Asthma acute exacerbation signs & symptoms

-progressive dyspnea
-chest tightness
-wheezing
-cough
-obvious respiratory distress
-auscultation of wheezes
-use of accessory muscle or nasal flaring
-altered LOC
-don't be fooled by the "quiet chest"

42

asthma acute exacerbation tx

airway management
oxygen
Beta 2 Agonists (bronchodilators): nebulized (SVN) (Albuterol)
Steroids: PO-prednisone, prelone; IV-solumedrol
Anticholinergics: nebulized (atrovent, ipratropium bromide)

admission or discharge decision within 1 hour

43

Usual protocol if asthma acute exacerbation

stacked SVN treatments w/bronchodilators:
-.5 cc albuterol in 2.5 cc normal saline, 3 txs given q 30mins
-peak flow rate before 1st & after 3rd tx
-determine if steroid therapy is needed
-look for underlying infection

44

Asthma acute exacerbation: questions to ask?

admit or discharge?
how much baseline respiratory distress?
vulnerable population?
how much improvement with each SVN?
underlying factors?
able to get follow-up care?
reliable to follow instructions for out-pt tx?

45

COPD & Emphysema: physiological what is going on in both

V/Q mismatch=areas of perfusion are not being ventilated
-wCO2 retention, hypoxic drive has long been lost & CO2 drive is being lost, these are very sick patients

46

COPD vs. Emphysema

COPD="blue bloaters", more bronchospasm & mucus plugging

emphysema="pink puffers", more loss of alveolar architecture

(U) some combination

47

Emphysema & COPD epidemiology

older population
smokers

48

Emphysema & COPD signs &sxs

-progressive dyspnea, may have been having dyspnea for days before presenting to the ED!
-chest tightness
-wheezing
-cough

49

Emphysema & COPD dx of exacerbation

-obvious respiratory distress
-wheezing
-use of accessory muscles
-altered LOC-ominous
-don't be fooled by the "quiet chest"
-change in sputum production & color

50

Emphysema & COPD tx

airway management
oxygen
Beta 2 agonists(bronchodilators):
nebulized (SVN) (albuterol)
Steroids: PO (prednisone, prelone), IV (Solumedrol)
Anticholinergics: nebulized (atrovent-ipratropium bromide)
Antibiotics
Admission or discharge decision within 1 hour
Very hard to extubate

51

Emphysema disposition/admission rate

higher admission rate than asthma
-older population
-more comorbid conditions
-more damage to the lungs

52

Pneumonia

inflammation of the lung caused by infection which causes the alveoli to become filled with pus so that air is excluded

53

Pneumonia signs & sxs (5)

fever
cough
dyspnea
pleuritic chest pain
respiratory failure

54

Pneumonia diagnosis (7)

auscultation
CXR
pulse oximetry
blood gasses
CBC
blood cultures
sputum Gram stain, C&S

55

Pneumonia treatment (5)

Airway management
Oxygen
Antibiotics
Beta 2 agonists
Analgesics

56

Congestive Heart Failure/Pulmonary Edema: definition and cause

inability of myocardium to adequately perfuse end-organs->fluid accumulation, arterial vasoconstriction-> further pump failure

most (C) cause=coronary ischemia
most (C) cause of right HF=left HF

57

CHF/PE (C) causes (4)

-MI
-valvular dysfxn (high output failure w/regurgitant lesions, stenosis lesions get critical very fast)
-cardiomyopathy (viral)
-systemic HTN (wall thickening then hypoperfusion

58

CHF/PE signs & sxs (5)

dyspnea
orthopnea
paroxysmal nocturnal dyspnea
fatigue
peripheral edema

59

CHF/PE diagnosis (8)

diaphoresis
tachypnea
tachycardia
pulmonary rales or wheezing
JVD-hepatojugular reflux
hepatomegaly
pitting peripheral edema
pulse oximetry

60

CHF/PE tx (5)

-Airway management
-Oxygen
-Vasodilators: nitrates (SL, topical, IV)
-Diuretics: furosemide (Lasix) 20-40 mg IV
-Inotropic agents (B1), dobutamine

61

Pneumothorax def

any breech of lung surface or chest wall allowing air to enter the pleural cavity, causing the lung to collapse

62

Pneumothorax signs & sxs (3)

-chest pain on side of collapsed lung
-dyspnea
-occasionally cough, but absence of other URI symptoms

63

Large pneumothorax dx (8)

-Decreased breath sounds
-tachypnea
-tachycardia
-TRACHEAL DEVIATION TO OPPOSITE SIDE
-HYPOTENSION
-cyanosis
-marked respiratory distress
-CXR

64

Pneumothorax tx

tx based on % involvement on CXR & overall pt presentation
<15-20% involvement: observation only, repeat CXR in 48 hrs

20% or more=intervention
-needle decompression
-simple aspiration
-tube thoracostomy (chest tube)

65

Pulmonary Embolism

venous thrombi dislodge & travel to the pulmonary arteries where they cause occlusion
-presenting signs & symptoms depend on how occluded pulmonary vasculature is & pre-existing cardiopulmonary dz

66

PE sxs

3 most common: dyspnea (81%), pleuritic chest pain (73%), cough (60%)
other sxs: any type of chest pain, wheezing, chest wall tenderness, anxiety, hemoptysis

67

PE: predisposing factors (6)

immobility (best rest, traction, etc)
heart dz
CA
estrogen therapy
previous DVT or PE
hypercoagulability

68

PE dx work-up

-almost always rule out MI so need ECG, cardiac enzymes
-pulse ox & ABGs controversial
-CXR
-V/Q scan (provides distribution of pulmonary blood flow by visualizing radioactivity after IV injection of radiolabeled albumin microaggregates)
-D-Dimer
-CT scan of chest

69

V/Q scan report

reported as low, intermediate or high probability
[low or intermediate DOES NOT RULE OUT]
high probability in a pt with strong risk factors->initiate therapy

70

Controversial PE workup

do a work-up for LE DVT?
-serial impedance plethysmography
-Doppler ultrasonography

gold standard dx test=pulmonary angiography, but it is invasive and risky (morbidity rate of 4%), so RARELY DONE

71

PE tx

supportive care
oxygen therapy
anticoagulation therapy
intensive monitoring
pain relief
surgical embolectomy
vena cava filter (Greenfield filter)