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Flashcards in Pulm Emergencies Deck (60)
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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