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Flashcards in Pulm Emergencies Deck (60):
1

Causes of upper airway obstruction?

- FB
- tongue
- swelling/edema

2

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?

3

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

4

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?

5

Where is the retropharyngeal space?

- extends from base of skull to tracheal bifurcation

6

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

7

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

8

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

9

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
or
ampicillin-sulbactam (Unasyn):
adult dose 1500-3000 mg q 6hr

10

Complications of Retropharyngeal abscess?

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

11

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

12

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

13

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

14

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

15

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

16

What is anaphylaxis?

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

17

Presentation of anaphylaxis?

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

18

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

19

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

20

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

21

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

22

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?

23

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

24

Pneumothorax?

- 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

25

RFs for spontaneous pneumo?

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

26

Presentation of spontaneous pneumo?

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

27

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
tachycardia
hypotension (shock)
tracheal shift
JVD

28

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

29

Presentation of acute pulmonary edema?

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

30

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

31

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

32

Chronic causes of cardiogenic pulmonary edema?

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

33

Causes of noncardiogenic pulmonary edema?

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

34

Etiology of ARDS?

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

35

Tx of Cardiogenic acute pulm edema?

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

36

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

37

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

38

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

39

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)

40

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

41

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

42

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
-DDx:
CHF, PE, pneumonia, pneumothorax

43

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 +/-
- EKG

44

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)

45

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

46

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

47

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

48

RFs for PE?

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

49

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

50

Tx for acute PE?

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

51

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

52

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

53

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

54

W/U for pneumonia?

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

55

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:
confusion
BUN less greater than 19mg/dl
respirations: greater than 30
sBP less than 90 or diastolic less than 60
age: older than 65

56

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

57

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
legionella

58

Tx for pneumonia (non-ICU pts)?

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

- usually Rocephin + azithro

59

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

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

60

Abx for ICU pneumonia?

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

for PCN allergy: resp fluoroquinolone + aztreonam