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EM quiz readings > Lecture 8: Dyspnea in the ED > Flashcards

Lecture 8: Dyspnea in the ED Flashcards

1
Q

What S/S suggest dyspnea?

A
  • Tachypnea/tachycardia
  • Stridor
  • Accessory muscle use (need pt undressed to see)
  • Inability to speak
  • Agitation/lethargy
  • Depressed consciousness
  • Paradoxical abdominal wall movement
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2
Q

What previous medication use is very pertinent to dyspnea evaluation?

A

Steroid use

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3
Q

What does a history of mechnical ventilation suggest for prognosis of current evaluation of dyspnea?

A

They will probably need ventilation AGAIN

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4
Q

What abdominal finding might be seen in PE for dyspnea?

A

Hepatomegaly/congestion

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5
Q

What is one of the earliest signs of hypoxia?

A

Acrocyanosis

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6
Q

What are the most immediate life-threatening causes of dyspnea?

A
  • Upper airway obstruction
  • Tension pneumo
  • Pulmonary embolism
  • Neuromuscular weakness (Myasthenia gravis, GBS, botulism)
  • Fat embolism
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7
Q

What are the MCC of dyspnea?

A
  • COPD
  • Decompensated HF
  • Ischemic heart disease
  • PNA
  • Psychogenic
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8
Q

What symptoms suggest HF as underlying etiology for dyspnea?

A
  • PND
  • Orthopnea
  • Edema
  • DOE
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9
Q

What diagnostic helps differentiate COPD/asthma from other disorders?

A

Decreased peak expiratory flow rate

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10
Q

What easy and quick diagnostic can help differentitate between acute cardiac vs noncardiac causes?

A

Bedside POCUS

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11
Q

Initial approach to managing dyspnea?

A

Maintain oxygenation

Treat O2 sat first!

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12
Q

Goals for hypoxia

A
  • PaO2 > 60 mmHg
  • O2 sat > 90%
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13
Q

What might cause us to keep O2 at a lower goal?

A

CO2 retainers, since they are chronically hypercapnic

They have a lower baseline!

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14
Q

What is the progression of o2 delivery?

A
  1. NC (0.25-4)
  2. Simple mask (6-10)
  3. NRB (10-15)
  4. HF NC (40 or higher is possible)

High flow NC has positive pressure as well

NRB is generally short-term, transitioning to ETT

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15
Q

What are the options for noninvasive ventilation?

A
  • CPAP
  • BiPAP

Use BiPAP if pt feels like they are suffocating against CPAP

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16
Q

MC sign of an upper airway obstruction

A

Stridor

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17
Q

MCC of stridor in a neonate?

A

Laryngotracheomalacia (weak larynx)

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18
Q

What should we always consider as a cause of stridor in kids?

A
  • Food and toys
  • MC in ages 1-3
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19
Q

How would a kid with a FB in their larynx/trachea present?

A
  • Stridor
  • Hoarseness
  • Complete apnea
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20
Q

How does a FB in the bronchi present for children?

A
  • Unilateral wheezing
  • Decreased breath sounds
21
Q

MC location for a FB in a child to cause choking?

22
Q

MC foods for a kid to choke on

A
  • Peanuts
  • Sunflower sseeds
  • Carrots (raw)
  • Raisins
  • Grapes
  • Hot dogs

Aka things that cant be chewed up well

23
Q

How do we approach tx of a suspected airway FB?

A
  • Life-saving interventions FIRST
  • Imaging
  • Bronchoscopy to confirm/rule out/remove FB
24
Q

Specifically for a bronchial FB, what views can help assess air trapping?

A

Inspiratory and expiratory PA views

25
What imaging is indicated for a tracheal FB?
PA and lateral **soft tissue neck**
26
What might suggest radiolucent FB on CXR?
* Unilateral obstructive emphysema with air trapping and mediastinal shift away * Focal atelectasis with complete obstructions * Consolidation => scarring
27
Describe a coin in the trachea
* PA/AP will show its side * Lateral will shows its face * **tcl (Trachea coin lateral)**
28
Describe a coin in the esophagus
* AP/PA shows the coin face * Lateral shows the coin side * **ecap (esophagus coin on AP)** | Esophagus is wide for food, so it shows the big side of the coin
29
Management of airway FB with complete obstruction
1. BLS 2. Direct laryngoscopy with FB extraction 3. Orotracheal intubation to dislodge FB if ^ fails 4. If ETT fails, needle cricothyroidotomy/tracheostomy 5. Consult pulm for emergency bronchoscopy if all else fails
30
Management of airway FB with only **partial obstruction**
Bronchscopy under general anesthesia
31
Prodrome of Croup/laryngotracheobronchitis
* Cough * Coryza * Mild fever | Croup is VIRAL
32
Classic presentation of Croup
* Inspiratory stridor * Barking * Seal like cough | Croup is VIRAL
33
Severities of Croup
* Mild: no stridor at rest * Mod: **Stridor at rest and mild** retractions * Severe: Stridor at rest + **severe retractions** + anxious + **fatigued**
34
Although imaging is not necessary to diagnose classic croup, what can we order and what would we see?
* Soft tissue neck XR * **Steeple sign** with normal epiglottitis * Narrowing of superior trachea * Subglottic haziness
35
Tx of mild croup
* Outpatient * **Single dose of oral dexamethasone** * Alternatives: IM dexa or neb budesonide
36
Tx of mod-sev Croup
* Single dose dexamethasone * **Nebulized/racemic epinephrine** * Humidified O2 * **Heliox if above fails** * **ETT last resort if everything else fails** | Heliox is 70-80% helium + 20-30% O2
37
Discharge criteria for croup | Must meet all
1. Nontoxic 2. No dehydration 3. O2 > 90% on RA 4. Reliable caregiver 5. Obs with improvement for 3 hrs post last epi 6. f/u in 24-48h with PCP | Must meet ALL
38
Admission indications for croup | Just meet 1
1. Persistent stridor at rest 2. Tachypnea 3. Retractions 4. Hypoxia 5. > 2 doses of nebulized epi are needed | Meet 1
39
Difference between bacterial tracheitis vs croup
* More severe resp distress * Toxic appearing * Thick, mucopurulent secretions causing upper airway obstruction * Sore throat: tenderness to trachea on palpation
40
Dx of Bacterial tracheitis
* Clinical (similar to how we dx croup) * Bronchoscopy after airway secure | Neck XR will show steeple sign ALSO
41
What are the goals of bronchoscopy for bacterial tracheitis?
* Confirmation of **edema of trachea** * Therapeutic removal of mucus * C&S of secretions
42
What do the kidneys regulate in terms of acid-base?
* HCO3- (base/alkalotic) * Compensation takes **12-24 hours to occur** | AKA respiratory acidosis is hard to correct quickly.
43
What do the lungs regulate in terms of acid-base?
* PCO2 (acid) * Compensation occurs **within minutes**
44
Why does aloveolar hypoventilation result in respiratory acidosis?
Preventing the CO2 from exchanging properly.
45
Acute causes of respiratory acidosis
* Head trauma * Chest trauma * Lung disease * Excess Sedation
46
What occurs that switches breathing to having a hypoxic drive?
Chronic PCO2 > 60-70 mmHg can depress the respiratory center. | HOWEVER, do not withhold O2 in pts if severely dyspneic.
47
What secondary condition can result from alveolar hyperventilation/respiratory alkalosis?
Ionized hypocalcemia.
48
Why do we give panic attacks a bag to breathe in?
Rebreathing their own CO2 so that they don't become alkalotic.

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