Flashcards in Pulm Emergencies Deck (60):
Causes of upper airway obstruction?
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?
- retropharyngeal abscess
- 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?
- 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
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:
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:
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
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
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?
- ages 20-40
- thin build
- 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
- suspect tension pneumo if:
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?
- frothy pink sputum (uncommon)
- pedal edema
- 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?
- 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?
- narcotic overdose
- transfusion related injury
- salicylate overdose
Etiology of ARDS?
- acute pulmonary infection
- 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?
- 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?
- lower extremity edema
- may have rales on exam
- lower extremity pain or erythema
RFs for PE?
- prolonged immobilization
- hormones: BCPs, HRT, SERMs
- recent jt replacement surgery
- hx of DVT
- autoimmune disease
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?
- 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
- 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?
- pleuritic chest pain
- sputum production
- mental status changes
- GI sxs (N/V/D)
- rales, rhonchi or decreased in area of consolidation
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)
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
- 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)
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