Pulm Emergencies Flashcards

1
Q

Causes of upper airway obstruction?

A
  • FB
  • tongue
  • swelling/edema
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2
Q

Upper airway obstruction assessment?

A
  • 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?
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3
Q

Etiology of upper airway obstruction?

A
  • fb
  • retropharyngeal abscess
  • angioedema
  • head and neck trauma
  • swelling/edema from inhalation injuries
  • epiglottitis, croup, tonsillitis, peritonsilar abscess, Ludwig’s angina
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4
Q

Difference b/t incomplete and complete FB obstruction?

A
  • 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?
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5
Q

Where is the retropharyngeal space?

A
  • extends from base of skull to tracheal bifurcation
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6
Q

Etiology of retropharyngeal abscess in kids, adults?

A
  • 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
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7
Q

Signs and sxs of retropharyngeal abscess?

A
  • 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
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8
Q

W/U of retropharyngeal abscess?

A
  • lateral soft tissue XR of neck during inspiration
  • on neck XR: see expansion of prevertebral soft tissues
  • CT scan of neck is Gold Std
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9
Q

Tx of Retropharyngeal abscess?

A
  • 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
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10
Q

Complications of Retropharyngeal abscess?

A
  • extension of infection into mediastinum: pleural or pericardial effusion
  • upper airway asphyxia
  • sudden rupture:
    aspiration pneumonia
    widespread infection
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11
Q

What is angioedema?

A
  • 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
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12
Q

Tx of angioedema?

A
  • rapid initial assessment of airway and close monitoring
  • intubation or surgical airway may be necessary
  • intubate immediately if any signs of resp distress
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13
Q

Tx of allergic angioedema?

A
  • 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
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14
Q

Tx of ACE inhibitor induced angioedema?

A
  • 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
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15
Q

Tx of hereditary angioedema?

A
  • 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

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16
Q

What is anaphylaxis?

A
  • acute, potentially lethal, multisystem syndrome from the sudden release of mast cells and basophils into circulation
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17
Q

Presentation of anaphylaxis?

A
  • sudden onset generalized urticaria (hives) - 10-20% will have no skin sxs
  • angioedema
  • flushing
  • pruritus
  • hypotension
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18
Q

Signs and Sxs of anaphylaxis?

A
  • 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
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19
Q

Tx of anaphylaxis?

A
  • 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
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20
Q

Overview of tx of anaphylaxis?

A
  • 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
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21
Q

Signs of head and neck trauma?

A
  • 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
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22
Q

Management of head and neck trauma?

A
  • 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?
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23
Q

What is diff b/t stupor and coma?

A
  • 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
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24
Q

Pneumothorax?

A
  • 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
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25
Q

RFs for spontaneous pneumo?

A
  • men
  • ages 20-40
  • thin build
  • smokers
  • family hx
  • marfan syndrome
  • prior episode has recurrence rate of 25-54%
26
Q

Presentation of spontaneous pneumo?

A
  • sudden onset of dyspnea and pleuritic chest pain

- often occurs at rest

27
Q

PE findings of pneumothorax?

A
  • 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
Q

Tx of pneumo?

A
  • 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
Q

Presentation of acute pulmonary edema?

A
  • dyspnea
  • frothy pink sputum (uncommon)
  • pedal edema
  • ascites
  • rales
  • wheezing
  • HTN
  • hypoxemia
  • restlessness
  • tachycardia
  • cold diaphoresis
30
Q

Etiologies of acute pulmonary edema?

A
  • from cardiogenic and noncardiogenic sources
  • from sudden increase in left sided intracardiac filling pressures
  • OR increased alveolar cap membrane permeability
31
Q

Acute causes of cardiogenic pulmonary edema?

A
  • ischemia
  • acute severe mitral regurgitation
  • acute aortic regurgitation
  • hypertensive crisis secondary to bilateral renal artery stenosis
  • stress induced cardiomyopathy
32
Q

Chronic causes of cardiogenic pulmonary edema?

A
  • decompensated systolic CHF
  • decompensated diastolic CHF
  • LVOT (left ventricular outflow tract) obstruction
  • valvular heart disease
33
Q

Causes of noncardiogenic pulmonary edema?

A
  • **ARDS
  • altitude
  • neurogenic
  • narcotic overdose
  • PE
  • eclampsia
  • transfusion related injury
  • salicylate overdose
34
Q

Etiology of ARDS?

A
  • 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
Q

Tx of Cardiogenic acute pulm edema?

A
  • O2 +
  • tx underling cause
  • ischemia: Rx nitrates, morphine, diuretics
  • valvular disease: diuretics
  • tx arrhythmias: ACLS protocol and diuretics
36
Q

Tx of Noncardiogenic acute pulm edema?

A
  • 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
Q

Tx of aspiration?

A
  • 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
Q

PP of asthma?

A
  • 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
Q

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

A
  • 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
Q

Assessment of acute asthma attack?`

A
  • 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
Q

Acute asthma meds?

A
  • 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
Q

Etology of COPD exacerbation? DDx for COPD?

A
  • 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
Q

Work up of COPD exacerbation?

A
  • O2 sats
  • ABG in severe exacerbations
  • CXR to assess for signs of pneumonia, acute heart failure, pneumothorax
  • CBC, BMP, BNP +/-
  • EKG
44
Q

Pharmacotherapy for COPD exacerbation?

A
  • 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
Q

When should you consider hosp admission for COPD exacerbation?

A
  • 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
Q

What is a PE?

A
  • obstruction of pulmonary artery or branches w/ clot, tumor, air or fat
  • common and often fatal disease
  • can be acute or chronic
47
Q

Signs and sxs of PE?

A
  • dyspnea
  • tachypnea
  • cough
  • hemoptysis
  • syncope
  • lower extremity edema
  • cyanosis
  • diaphoresis
  • hypotension
  • may have rales on exam
  • lower extremity pain or erythema
48
Q

RFs for PE?

A
  • pregnancy
  • obesity
  • prolonged immobilization
  • hormones: BCPs, HRT, SERMs
  • cancer
  • trauma
  • recent jt replacement surgery
  • hx of DVT
  • autoimmune disease
  • HTN
  • smoking
  • CHF
49
Q

W/U of PE?

A
  • 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
Q

Tx for acute PE?

A
  • 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
Q

use of anticoagulants in PE tx?

A
  • 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
Q

When do you use thrombolytics in acute PE?

A
  • 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
Q

SIgns and sxs of pneumonia?

A
  • 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
Q

W/U for pneumonia?

A
  • 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
Q

Indications for hosp admission of pneumonia pt?

A
  • 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
Q

Tx for pneumonia?

A
  • 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
Q

Pathogens of pneumonia?

A
  • 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
Q

Tx for pneumonia (non-ICU pts)?

A
  • resp fluoroquinolones (levo, moxi, gemifloxacin)
    or
  • antipneumococcal beta-lactam (cefotaxime, ceftriaxone, or ampicillin-sulbactam)
    PLUS
    Macrolide (azithro, clarithro, or erythromycin)
  • usually Rocephin + azithro
59
Q

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

A
  • S. pneumoniae, legionella, gram negative bacilli, staph aureus and consider MRSA
60
Q

Abx for ICU pneumonia?

A
  • 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