Airway and Respiratory Emergencies

Question 1

How does a pt look with respiratory failure?

Answer 1

Hypoxemia and hypercarbia
Respiratory exhaustion
Use of accessory muscles
Retractions

Question 2

What does 4 min signify with complete obstruction?

Answer 2

From the time of complete obstruction to onset of brain damage (FRC has 21% oxygen)

Question 3

Most common cause of airway obstruction

Answer 3

Tongue

Question 4

Progression of airway obstruction

Answer 4

Partial will often go to complete if not cleared

Complete with progress to respiratory arrest if not cleared

Question 5

How does a pt look with complete airway obstruction?

Answer 5

Chest will move in “rocking motion” with abdomen going in opposite direction

Question 6

Who must perform the most invasive airway management?

Answer 6

Most experienced practitioner

Question 7

Types of airways

Answer 7

Oral
Nasal
Laryngeal mask airway

Question 8

Presentation of foreign body aspiration in a toddler

Answer 8

Persistent cough and unilateral wheezing if gone down 1 bronchi
No URI sxs
Decreased breath sounds
Post-obstructive atelectasis, pneumonia

Question 9

Location of foreign bodies

Answer 9

Larynx
Tracheal/ carina
Right lung (MOST- most here is main bronchus)
Left lung (second most common)
Bilateral

Question 10

What is important to remember with intubation and facial burns?

Answer 10

Intubate early with facial or large scale burns because if you wait too long the trachea will close and can’t intubate

Question 11

Types of Le Forte fractures

Answer 11

I- maxilla is disconnected b/c fracture goes straight across and upper teeth are loose
II- through cheek bones and under the orbits
III- fractures through the orbits

Question 12

What fractures are likely to have cribriform fractures?

Answer 12

LeForte II and III

Question 13

What MUST you remember with LeForte II and III?

Answer 13

No nasal airways!!! (b/c possible cribriform)

Question 14

What is seen on a pt with a basilar skull fracture?

Answer 14

Battle’s sign (bruising of mastoid- mid skull fracture)
Raccoon eyes (frontal fracture)
CSF from nose and/or ears

Question 15

Pathophysiology of anaphylaxis

Answer 15

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

Question 16

Common causes of anaphylaxis

Answer 16

Abx
ASA and NSAIDs
Shellfish, nuts, eggs, milk
Hymenopytera (bee) stings, grasses

Question 17

Presentation of anaphylaxis

Answer 17

Onset in seconds to hours
Angioedema
Tightening sensation in throat and chest
Laryngeal swelling and bronchial spasm, hoarseness, stridor, wheezing (BILATERAL)
Respiratory distress and apnea

Question 18

Tx for anaphylaxis

Answer 18

Airway management and O2
Epi if severe hypotension (IV .3-.5 mg of 1:10,000 or SC .3-.5 mg of 1:1,000)
Antihistamines (H1 like diphenhydramine or H2 like cimetidine)

Question 19

What can also be considered in some anaphylaxis cases?

Answer 19

Beta 2 agonists (albuterol)
Steroids
Endotracheal intubation
Surgical airway
IV bolus if hypotensive

Question 20

What is angioedema?

Answer 20

Eruption similar to urticaria but with larger edematous areas that involve dermis and subQ structures
Frequently head and neck
Onset in minutes to hours and resolves in hours to days

Question 21

2 types of angioedema

Answer 21

Hereditary- insufficient synthesis of C1-esterase inhibitor (rare and autosomal dominant)
Acquired (ACE-i)

Question 22

Tx for angioedema

Answer 22

Airway and support
Plasma conc of C1 esterase inhibitor if hereditary
Epi, antihistamines, steroids
Danazol to increase synthesis of C1 esterase inhibitor
Ecallantide (kallikrein inhibitor)
Icatibant (bradykinin receptor antagonist)

Question 23

What does C1 esterase inhibitor usually do?

Answer 23

Prevent the build up of bradykinin

Question 24

What is ludwig’s angina?

Answer 24

Bilateral, rapidly spreading submandibular cellulitis

Usually originating from 2nd or 3rd molars

Question 25

Sxs of ludwig's angina

Answer 25

``` Tongue elevated Hard, firm induration of floor of the mouth Perioral edema Pain Trismus Mediastinitis ```

Question 26

Tx for ludwig's angina

Answer 26

Must be surgery Awake fiberoptic nasal intubation Sometimes awake tracheostomy

Question 27

What is the retropharyngeal abscess?

Answer 27

Localized collection of pus in the retropharyngeal space (rare)

Question 28

Causes of a retropharyngeal abscess

Answer 28

``` Mixed gram - and anaerobic bacteria Tonsillitis Otitis media Pharyngeal trauma Odynophagia ```

Question 29

Sxs of a retropharyngeal abscess

Answer 29

Fever, odynophagia (classic!), neck swelling, drooling, torticollis, meningismus, cervical LAD, stridor, airway obstruction

Question 30

Ways to diagnose retropharyngeal abscess

Answer 30

Clinical Soft tissue lateral neck x-rays (gas, mass) CT neck

Question 31

Tx for retropharyngeal abscess

Answer 31

Airway management | Abx, admit, drainage

Question 32

What is epiglottitis?

Answer 32

Infection of the supraglottic structures including epiglottis, lingual tonsillar area, epiglottic folds and false vocal cords EMERGENCY

Question 33

Who does epiglottitis happen in?

Answer 33

Age 2-7 (before H flu B vaccine) Sometimes in adults HIB, strep, staph

Question 34

Sxs of epiglottitis

Answer 34

Abrupt onset over hrs | Fever, stridor, toxic appearance, dys and odynophagia, drooling, tripod, altered LOC, cyanosis, airway obstruction

Question 35

What MUST you remember with epiglottitis?

Answer 35

Never stick a tongue blade in the throat (do a soft tissue lateral neck x-ray if stable)

Question 36

X-ray for epiglottitis

Answer 36

Thumb sign

Question 37

Tx for epiglottitis

Answer 37

Immediate control of airway | Abx when secure airway (3rd gen cephalosporin like ceftriaxone)

Question 38

What is croup (laryngotracheobronchitis)?

Answer 38

Usually benign, self limited inflammatory condition of the trachea below level of vocal cords usually caused by parainfluenza virus

Question 39

Who do you see croup in?

Answer 39

``` 6 mos-3 yrs Can see up 15 yrs tho Increased in winter Can be RSV *smaller pt, more likely to go into respiratory distress ```

Question 40

Sxs of croup

Answer 40

2-3 day history of URI Low grade fever Gradual worsening, barking seal cough (especially at night) Stridor, dyspnea, retractions, tachypnea

Question 41

Xray for croup

Answer 41

Steeple sign (not sensitive or specific)

Question 42

Tx of croup

Answer 42

Airway management Cool mist, maybe O2 Nebulized epi (observe for 3-4 hrs after tx) Steroids (prednisolone for 1 mg/kg or dexamethazone for .15-.6 mg/kg IM or PO)

Question 43

What causes whooping cough?

Answer 43

Bordetella pertussis (gram - aerobe)

Question 44

Who is at highest risk for whooping cough?

Answer 44

Unvaccinated infants and toddlers

Question 45

Sxs of whooping cough

Answer 45

``` URI sxs in early stage and paroxysms of cough later NO FEVER Inspiratory stridor in younger pts Post-tussive vomiting!! Increased WBCs and lymphocytes ```

Question 46

How to diagnose whooping cough?

Answer 46

Nasopharyngeal swab on special culture media (gold standard) | -Can do PCR with shorter turn around

Question 47

Who is the risk for with whooping cough in unvaccinated kids?

Answer 47

Sudden infant death and airway compromise | *also treat unprotected contacts

Question 48

Sxs of lower respiratory tract infections

Answer 48

Usually start with URI and progress to lower | Dyspnea, hypoxemia, apnea, acute respiratory failure

Question 49

What is bronchiolitis?

Answer 49

Clinical syndrome in infancy characterized by rapid respiration, chest retractions and wheezing

Question 50

When is bronchiolitis seen in pts?

Answer 50

Winter Males more 0-2 YO (peaks at 2-6 mos) Most common cause is RSV!!

Question 51

Pathophysiology of bronchiolitis

Answer 51

Bronchiolar obstruction from submucosal edema and mucous plugging and bronchoconstriction

Question 52

When do you order an Xray in bronchiolitis?

Answer 52

Increased temp, choking, asymmetric chest exam, respiratory distress, sudden deterioration

Question 53

Sxs of bronchiolitis

Answer 53

Runny nose/ sneezing, low grade fever, dyspnea, tachypnea, intercostal retractions, wheezing, cyanosis and apnea

Question 54

How to diagnose bronchiolitis?

Answer 54

Clinical CXR- hyperinflated lungs Pulse ox to see hypoxia Viral cultures and fluorescent monoclonal antibody testing of NP swabs

Question 55

Tx for bronchiolitis

Answer 55

``` Airway, support Mild cases can be observed at home and admit others O2, beta agonists NO STEROIDS Ribavirin for severely ill or intubated ```

Question 56

What characterizes asthma?

Answer 56

Paroxysmal attacks of reversible bronchospasm, mucous plugging and inflammation of tracheobronchial tree

Question 57

Sxs of acute exacerbation of asthma

Answer 57

Progressive dyspnea, chest tightness, wheezing, cough, respiratory distress

Question 58

Tx for acute exacerbation of asthma

Answer 58

Airway and O2 Beta 2 agonists, steroids, anticholinergics (atrovent) Must decide admit or discharge quickly

Question 59

Usual protocol for acute exacerbation of asthma

Answer 59

Stacked SVN txs with bronchodilators (.5 cc albuterol in 2.5 cc normal saline)--3 txs every 30 min Maybe steroids

Question 60

What is status asthmaticus?

Answer 60

FEV1 that does not increase to greater than 40% predicted value with tx (develop major complications like a pneumo)

Question 61

What to do with a pt with status asthmaticus?

Answer 61

Beta agonists, high dose steroids, O2 | ADMIT

Question 62

What is pneumonia?

Answer 62

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

Question 63

Sxs of pneumonia

Answer 63

Fever, cough, dyspnea, pleuritic chest pain, respiratory failure

Question 64

Tx for pneumonia

Answer 64

Airway management and O2 | Abx, beta 2 agonists, analgesics

Question 65

Sxs of pneumothorax

Answer 65

Chest pain on side of collapsed lung Dyspnea Occasional cough (but absence of other URI sxs)

Question 66

How to diagnose tension pneumothorax

Answer 66

``` Decreased breath sounds Tachycardia and tachypnea Tracheal deviation Hypotension, cyanosis, respiratory distress CXR ```

Question 67

Tx for pneumothorax with <15-20% involvement

Answer 67

Observe and repeat CXR in 48 hrs

Question 68

Tx for pneumothorax with >20%

Answer 68

Needle decompression for tension pneumothorax Simple aspiration Tube thoracostomy (chest tube)