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Flashcards in Pulm Emergencies Deck (60)
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Causes of upper airway obstruction?

- FB
- tongue
- swelling/edema


Upper airway obstruction assessment?

- air movement?
- stridor or snoring
- ability to talk and/or swallow?
drooling, muffled voice
- assoc SOB
- vital signs needs to include O2 sats
- is pt stable or unstable?


Etiology of upper airway obstruction?

- fb
- retropharyngeal abscess
- angioedema
- head and neck trauma
- swelling/edema from inhalation injuries
- epiglottitis, croup, tonsillitis, peritonsilar abscess, Ludwig's angina


Difference b/t incomplete and complete FB obstruction?

- incomplete: if just in nose, what sxs may they have?
should hear some noise (stridor)
- complete obstruction of upper airway: Heimlich, Magill forceps, do they need cricothyroidotomy?


Where is the retropharyngeal space?

- extends from base of skull to tracheal bifurcation


Etiology of retropharyngeal abscess in kids, adults?

- kids: usually from lymph node that drains the head and neck
- adults: penetrating trauma (chicken bones), from an infection in mouth/teeth, lymph nodes that drain head and neck


Signs and sxs of retropharyngeal abscess?

- fever
- dysphagia
- neck pain
- limitation of cervical motion
- cervical lymphadenopathy
- sore throat
- poor oral intake
- muffled voice
- respiratory distress
- stridor more likely in kids
- inflammatory torticollis


W/U of retropharyngeal abscess?

- lateral soft tissue XR of neck during inspiration
- on neck XR: see expansion of prevertebral soft tissues
- CT scan of neck is Gold Std


Tx of Retropharyngeal abscess?

- immediate ENT consult
- tx is surgical incision and drainage
- IV hydration and IV abx to be started in ER
clindamycin: adult dose 600-900 mg IV q 8hr
ampicillin-sulbactam (Unasyn):
adult dose 1500-3000 mg q 6hr


Complications of Retropharyngeal abscess?

- extension of infection into mediastinum: pleural or pericardial effusion
- upper airway asphyxia
- sudden rupture:
aspiration pneumonia
widespread infection


What is angioedema?

- subdermal or submucosal swelling
- swelling is diffuse and nonpitting
- can occur in isolation, w/ urticaria, or as component as anaphylaxis
- affects face, lips, mouth, throat, larynx, extremites, genitalia and possibly bowel (colicky abdominal pain)
- often asymmetric swelling


Tx of angioedema?

- rapid initial assessment of airway and close monitoring
- intubation or surgical airway may be necessary
- intubate immediately if any signs of resp distress


Tx of allergic angioedema?

- if mast cell mediated (allergic):
epinephrine 0.3 mg IM
glucocorticoids (Methylprednisolone 60-80 mg IV or oral prednisone 40 mg)
diphenhydramine 25-50 mg IV


Tx of ACE inhibitor induced angioedema?

- intubate immediately if signs of respiratory distress
- d/c offending drug (ACEI), usually sxs resolve in 24-72 hrs
- if swelling is severe or no improvement in 24 hr:
antihistamines, glucocorticoids
C1 inhibitor therapy (recombinant C1 inhibitor obtained from milk transgenic rabbit or from donated blood/FFP


Tx of hereditary angioedema?

- intubate immediately if any signs of respiratory distress
- bradykinin receptor antagonist is 2nd line therapy if C1 inhibitor concentrate not available from FFP or Ruconest


What is anaphylaxis?

- acute, potentially lethal, multisystem syndrome from the sudden release of mast cells and basophils into circulation


Presentation of anaphylaxis?

- sudden onset generalized urticaria (hives) - 10-20% will have no skin sxs
- angioedema
- flushing
- pruritus
- hypotension


Signs and Sxs of anaphylaxis?

- swelling of conjunctiva
- runny nose
- swelling of lips, tongue and/or throat
- heart and vasculature: fast or slow HR, low BP
- skin: hives, itchiness, flushing
- pelvic pain
- CNS: lightheadedness, LOC, confusion, HA, anxiety
- resp: SOB, wheezes or stridor, hoarseness, pain w/ swallowing, cough
- GI: crampy abdominal pain, diarrhea, vomiting, loss of bladder control


Tx of anaphylaxis?

- Epi (all other tx are supportive and don't reverse the process)
- adults: 0.3-0.5 mg IM q 5-15 min x3 if needed
- kids: 0.1 mg/kg w/ max dose of 0.5 mg
- give 5-15 min up to 3 doses
- Airway management: immediate assessment for wheezing, stridor, diff breathing, immediate intubation if marked stridor or resp arrest, may reqr a surgical airway


Overview of tx of anaphylaxis?

- assess airway/do they need to be intubated?
- simult. give IM epi
- O2 via nonrebreather (if airway patent)
- 2 large bore IV access sites: NS bolus 1-2 L initially, 20ml/kg in kids
- consider albuteral neb 2.5 mg, H1 blocker (diphenhydramine 50 mg IV), H2 blocker (ranitidine 50 mg IV), methylprednisolone (solu-medrol 125 mg IV)
- vasopressors for shock may be necessary


Signs of head and neck trauma?

-gurgling: pooling of liquids in oral cavity or hypopharynx
-snoring: partial airway obstruction at pharyngeal level from the tongue
- stridor:
inspiratory: obstruction at level of larynx
expiratory: obstruction at level of trachea
- wheezing: narrowing of lower airways


Management of head and neck trauma?

- secure airway while simult. protecting brain and c-spine from further injury
- jaw thrust and suctioning can often clear airway
- mandibular fx may need to displace tongue forward to maintain patent airway
- avoid nasotracheal intubation w/ midface trauma to avoid communication w/ cranium
- RSI vs intubation w/o paralytics: how hard are they to adequately BVM ventilate? Need to prep for cric prior to RSI? If hypopharynx is intact will an LMA suffice for back up?


What is diff b/t stupor and coma?

- both: inability to protect airway due to lack of gag reflex
- oropharyngeal airway vs intubation
- stupor: is lack of critical cog fxn and level of consciousness wherein a sufferer is almost entirely unresponsive and only responds to base stimuli such as pain
- coma: state of unconsciousness lasting more than 6 hrs, in which a person: can't be awakened, fails to respond normally to painful stimuli, light or sound; lacks normal sleep-wake cycle, and doesn't initiate voluntary actions



- accum of air in pleural space
- can be spontaneous or trauma induced
- spontaneous: pneumo that occurs w/o precipitating event in a person w/o a lung disease


RFs for spontaneous pneumo?

- men
- ages 20-40
- thin build
- smokers
- family hx
- marfan syndrome
- prior episode has recurrence rate of 25-54%


Presentation of spontaneous pneumo?

- sudden onset of dyspnea and pleuritic chest pain
- often occurs at rest


PE findings of pneumothorax?

- decreased chest exursion
- decreased breath sounds on affected side
- hyperresonant to percussion
- possible subq emphysema
- hypoxemia
- suspect tension pneumo if:
labored breathing
hypotension (shock)
tracheal shift


Tx of pneumo?

- supp O2 (b/f and after decompression) w/ nasal cannula
- needle decompression followed by chest tube placement (unstable) or primary tx w/ chest tube
- choice above depends on how stable the pt is
- decompression is done at 2nd and 3rd ICS at midclavicular line and/or at 5th ICS at anterior axillary line


Presentation of acute pulmonary edema?

- dyspnea
- frothy pink sputum (uncommon)
- pedal edema
- ascites
- rales
- wheezing
- hypoxemia
- restlessness
- tachycardia
- cold diaphoresis


Etiologies of acute pulmonary edema?

- from cardiogenic and noncardiogenic sources
- from sudden increase in left sided intracardiac filling pressures
- OR increased alveolar cap membrane permeability


Acute causes of cardiogenic pulmonary edema?

- ischemia
- acute severe mitral regurgitation
- acute aortic regurgitation
- hypertensive crisis secondary to bilateral renal artery stenosis
- stress induced cardiomyopathy


Chronic causes of cardiogenic pulmonary edema?

- decompensated systolic CHF
- decompensated diastolic CHF
- LVOT (left ventricular outflow tract) obstruction
- valvular heart disease


Causes of noncardiogenic pulmonary edema?

- ****ARDS
- altitude
- neurogenic
- narcotic overdose
- PE
- eclampsia
- transfusion related injury
- salicylate overdose


Etiology of ARDS?

- sepsis
- acute pulmonary infection
- trauma
- inhaled toxins
- shock lung
- freebase cocaine smoking
- post CABG
-inhalation of high conc of O2
- acute radiation pneumonitis


Tx of Cardiogenic acute pulm edema?

- O2 +
- tx underling cause
- ischemia: Rx nitrates, morphine, diuretics
- valvular disease: diuretics
- tx arrhythmias: ACLS protocol and diuretics


Tx of Noncardiogenic acute pulm edema?

- O2 +
- tx underlying cause
- if ARDS likely will need intubation and mechanical ventilation w/ PEEP
- diuretics may be somewhat helpful: furosemide (lasix) 40-80 mg IV - only if hemodynamically stable


Tx of aspiration?

- massive aspiration reqrs immediate protection of airway from further injury by intubation
- once intubated can lavage and suction lower airway
- tx underlying cause:
prolonged BVM during CPR
neuro ompromise secondary to stroke, SAH, head injuries


PP of asthma?

- inflammation of airways w/ an abnormal accum of eosinophils, lymphocytes, mast cells, macrophages, dendritic cells and myofibroblasts
- reduction in airway diameter caused by smooth muscle contraction, vascular congestion, bronchial wall edema, and thick secretions


acute asthma attack - Beware signs? Signs of resp failure?

- beware of: use of accessory muscles of respiration, fragmented speech, orthopnea, diaphoresis, agitation, low BP (consider anaphylaxis), severe sxs that fail to improve w/ initial tx
- impending resp failure: inability to maintain resp effort and rate, cyanosis, depressed mental status, severe hypoxemia, (SpO2 95% or less despite high flow O2 by nonrebreather)


Assessment of acute asthma attack?`

- measure peak flow if able
- supp O2
- ABGs generally not useful initially
- CXR not usefully initially
- est IV access
- frequent reassessment to determine if intubation and mechanical ventilation is needed
peak flow: helps give objective measurement as to severity of airflow obstruction
- peak flow less than 40% of predicted = severe
- measure b/f and after each neb or MDI tx


Acute asthma meds?

- albuterol:bronchodilator
- ipratropium bromide (atrovent, anticholinergic): bronchodilator
- methylprednisolone: glucocorticoid (decrease airway inflammation)
- Mg sulfate: for life threatening exacerbations that remain severe after 1 hr of intense bronchodilator therapy
- Epi: for suspected anaphylactic rxn or unable to use inhaled bronchodilators
- terbulatine: for severe asthma unresponsive to std therapies
**don't give both terbutaline and Epi


Etology of COPD exacerbation? DDx for COPD?

- most often precipitated by a viral or bacterial infection
- increase or change in character of usual sxs of dyspnea, cough or sputum production
CHF, PE, pneumonia, pneumothorax


Work up of COPD exacerbation?

- O2 sats
- ABG in severe exacerbations
- CXR to assess for signs of pneumonia, acute heart failure, pneumothorax
- CBC, BMP, BNP +/-


Pharmacotherapy for COPD exacerbation?

- supp O2 to maintain sats over 90%
- solumedrol (methylprednisolone) 60 mg IV
- abx to tx a respiratory source of infection and to include pseudomonas coverage (levaquin)
- inhaled bronchodilators: albuterol 2.5 mg and Atrovent 0.05 mg via nebulizer (Duoneb)


When should you consider hosp admission for COPD exacerbation?

- sxs are severe enough to prevent the pt from doing basic fxns like sleeping, preparing meals or walking to bathroom
- failure to respond to initial therapy
- high risk comorbidities like pneumonia, CHF, arrhythmia, liver failure, kidney failure or DM
- if impending respiratory failure:
intubation vs NIPPV


What is a PE?

- obstruction of pulmonary artery or branches w/ clot, tumor, air or fat
- common and often fatal disease
- can be acute or chronic


Signs and sxs of PE?

- dyspnea
- tachypnea
- cough
- hemoptysis
- syncope
- lower extremity edema
- cyanosis
- diaphoresis
- hypotension
- may have rales on exam
- lower extremity pain or erythema


RFs for PE?

- pregnancy
- obesity
- prolonged immobilization
- hormones: BCPs, HRT, SERMs
- cancer
- trauma
- recent jt replacement surgery
- hx of DVT
- autoimmune disease
- smoking


W/U of PE?

- CTA of chest w/ PE protocol
- CXR: see Hampton's hump
- EKG: sinus tach MC, S1Q3T3 arrhythmia w/ PE
- Echo +/-
- V/Q scan?
- D-dimer?
- doppler US of LE
- Pulmonary angiogram is old Gold standard


Tx for acute PE?

- supp O2
- if hypotension:
fluid bolus of 500-1000 ml NS
NE, dopamine, epi, dobutamine+NE
- Thrombolytics
- anticoagulants
- if thrombolytic therapy CI:surgical or catheter embolectomy


use of anticoagulants in PE tx?

- UFH: use in unstable pts in case you need to stop anticoag and trial thrombolytics
- LMWH: Enoxaparin (lovenox)
- Fondaparinux (Arixtra): give if pt has hx of allergy to Heparin or hx of HITT

- a Vit K agonist such as warfarin should be started on same day as anticaog therapy
- continue w/ lovenox until INR is 2.0


When do you use thrombolytics in acute PE?

- pts w/ acute PE assoc w/ hypotension needed vasopressor support or if hemodynamically unstable (massive PE) who don't have a high bleeding risk


SIgns and sxs of pneumonia?

- cough
- fever
- chills
- pleuritic chest pain
- dyspnea
- sputum production
- mental status changes
- GI sxs (N/V/D)
- tachypnea
- tachycardia
- hypoxia
- rales, rhonchi or decreased in area of consolidation


W/U for pneumonia?

- PA and lateral CXR
- blood cultures*
- sputum for gram stain and culture*
- pneumococcal and legionella urine abx tests*
(* these tests aren't necessary for outpts)


Indications for hosp admission of pneumonia pt?

- SpO2 less than 92%, febrile less than 35C or greater than 40C, RR greater than 30, tachycardia equal to or greater than 125, low SBP less than 90 mmHg
- pneumonia severity index:
takes into account age, mental status, pulse, RR, BP, hx of neoplastic disease, CHF, CVA, renal, and liver disease
- CURB 65:
BUN less greater than 19mg/dl
respirations: greater than 30
sBP less than 90 or diastolic less than 60
age: older than 65


Tx for pneumonia?

- supp O2
- intubation or NIPPV if impending respiratory failure
- abx to target most likely pathogen
- fluids for dehydration or hypotension
- antipyretics
- albuterol neb tx +/-
- incentive spirometry


Pathogens of pneumonia?

- most likely: Strep pneumoniae

- pts reqring hosp admission (non-ICU) - common pathogens besides S. pneumoniae:
resp viruses (influenza, RSV, parainfluenza)
M pneumoniae
H. influenza
C. pneumoniae


Tx for pneumonia (non-ICU pts)?

- resp fluoroquinolones (levo, moxi, gemifloxacin)
- antipneumococcal beta-lactam (cefotaxime, ceftriaxone, or ampicillin-sulbactam)
Macrolide (azithro, clarithro, or erythromycin)

- usually Rocephin + azithro


Most likely pathogens for pts w/ pneumonia that reqr ICU?

- S. pneumoniae, legionella, gram negative bacilli, staph aureus and consider MRSA


Abx for ICU pneumonia?

- antipneumococcal beta-lactam (cefotaxime, ceftriaxone, or amp-sulbactam) + azithro
- antipneumococcal beta-lactam (cefotaxime, ceftriaxone, or amp-sulbactam) + resp fluoroquinolone (moxi, gemi, or levofloxacin)

for PCN allergy: resp fluoroquinolone + aztreonam