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EM Board exam > Pulmonary > Flashcards

Pulmonary Flashcards

(51 cards)

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1
Q

A-a gradient

Description

Shorthand formula

A

A-a gradient = Measured PaO2 - Calculated PaO2

Quick A-a formula: 150 – (PaCO2 x 1.2 + PaO2)

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2
Q

Elevated A-a gradient ddx

A

V/Q Mismatch

–(PE, pneumonia, asthma)

Impaired O2 diffusion

–(interstitial pneumonia, PCP)

Right to Left Shunt

–(congenital heart disease)

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3
Q

Normal A-a gradient ddx

A

Hypoventilation

–(opioid OD)

Decreased FiO2

–(high altitude)

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4
Q

Central cyanosis clinically apparent with hemoglobin greater than

saturated carboxyhemoglobin looks like SaO2

saturated methemoglobin looks like SaO2

A

5 g/dL

100%
85%

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5
Q

Asthma pathophysiology

Bronchial *** and ***

Mucous ***

Increased *** cells

Bronchial muscle ***

A

Bronchial constriction and edema

Mucous plugging

Increased goblet cells

Bronchial muscle hypertrophy

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6
Q

Samter’s triad

A

asthma, recurrent sinus disease with nasal polyps, and a sensitivity to aspirin and other non-steroidal anti-inflammatory drugs (NSAIDs)

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7
Q

Asthma miscellaneous

measurement predicting need for admission

Hemodynamic sequelae

A

FEV1

hypotension, pulsus paradoxus

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8
Q

Death risk factors (just for review)

A
  • Hx of sudden severe exacerbations
  • Prior intubation
  • Prior ICU admit
  • >1 admission or >2 ED visits in past year
  • ED visit in past month
  • >2 adrenergic MDIs per month
  • Current/recent systemic steroid use
  • “Poor perceivers”
  • Concomitant disease – cardiopulmonary or psychosocial
  • Illicit drug use
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9
Q

Asthma
beta-2 agonists comparison review

A

–Inhaled superior to oral and parenteral routes, fewer side effects

–Intermittent equal to continuous administration

–MDIs equal to nebulizers

–Racemic equal to “R” enantiomer preparations (levalbuterol)

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10
Q

Asthma, mechanism of action
steroids (3)

inhaled anticholinergic
magnesium

ketamine

A

steroids: immunomodulatory, up regulates beta receptors, immediately causes vasoconstriction

inhaled anticholinergic: relaxes bronchial smooth muscle
magnesium: relaxes bronchial smooth muscle

ketamine: sedation and bronchodilation

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11
Q

Cardiac arrest, intubated asthma patient steps (4)

A

1 Disconnect ventilator

2 Compress chest

3 Bilateral chest tubes

4 Fluid bolus

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12
Q

Bronchiolitis medication for congenitally ill child

A

Ribavirin

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13
Q

COPD
unique pathophysiology from asthma

A

–Different inflammatory markers from asthma (e.g. neutrophils, not eosinophils)

–Proteases and oxidants result in tissue destruction

  • airflow reduction is not fully reversible and generally progressive
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14
Q

COPD

long-term natural history (4)

A

–Destruction of pulmonary vascular bed and thickened vessel walls

–Pulmonary hypertension

–Polycythemia

–Right sided heart failure (cor pulmonale)

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15
Q

In the setting of COPD exacerbation

A

Deep sulcus sign on the left suggestive of occult pneumothorax

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16
Q

COPD pneumothorax caveat

A

Blebs can mimic pneumothorax as shown on the x-ray

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17
Q
A
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18
Q

In the setting of COPD exacerbation

A

Lobar atelectasis distinguished from pneumonia by
sudden decompensation
volume loss on the affected side
may be treated by bronchoscopy

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19
Q

COPD therapy

indication for antibiotics

disease altering interventions (3)

A

abx: increased sputum production and purulent

smoking cessation and home oxygen (for PaO2 < 55 or Cor Pulmonale)- > mortality benefit
pneumococcal vaccination

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20
Q

ARDS
description
diagnostic criteria (3)

A

Non-cardiogenic pulmonary edema due to leaky alveolar capillary membranes
Diagnosis:

1 HypoxiaPaO2 < 60 mm Hg with FiO2 > 0.5

2 Normal ventricular function: PCWP < 18 mm Hg

3 Diffuse alveolar infiltrates: with normal heart size

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21
Q

ARDS
review of causes with most common

Study These Flashcards
A

–Sepsis (most common)

–Trauma

–Near-drowning

–Aspiration

–Toxicologic (ASA, opiates, hydrocarbons)

–Pancreatitis

–Environmental (high-altitude)

–Fat or amniotic fluid embolus

–CNS catastrophe (e.g. SAH)

22
Q

ARDS
treatment (4)

Study These Flashcards
A

PEEP/CPAP

pressure controlled/high-frequency ventilation
low tidal volume ~6 mL/kg

prone position

23
Q

Pneumonia mimics
including “*** lung”, *** gas

Study These Flashcards
A
  • Cancer
  • Tuberculosis
  • Pulmonary embolus
  • Toxicologic / environmental: Chlorine gas, Farmer’s lung (allergic reaction to inhalation of moldy crops – hay, grain, tobacco)
  • ARDS e.g. from chronic ASA toxicity or other treatable cause
  • Atelectasis
  • Right-sided endocarditis with Septic emboli
  • Diffuse alveolar hemorrhage: Low hemoglobin, immune disease
24
Q
Study These Flashcards
A

Multiple “cannonball” infiltrates

Suggestive of metastatic disease, septic emboli, right sided-endocarditis

25
Hamptons hump: wedge-shaped pulmonary infarction broadest at the pleural edge suggestive of pulmonary embolism
26
Pneumonia microbial risk associations COPD/smoker post viral/IVDA alcoholics, COPD, diabetics nosocomial, immunocompromised, CF alcoholics, poor dentition
COPD/smoker: Haemophilus influenza post viral/IVDA: staph aureus alcoholics, COPD, diabetics: Klebsiella nosocomial, immunocompromised, CF: Pseudomonas alcoholics, poor dentition: anaerobes
27
Noninfectious plural effusion associations right (2) left (3)
right (2): aortic dissection, Boerhaave's left (3): CHF, pancreatitis, hepatitis
28
Infectious pleural effusion associations (5)
Strep pneumonia, staph aureus, Haemophilus influenza, TB, Legionella
29
Lung abscess associations (4) including most common
Anaerobes (most common cause), Staph aureus, Pseudomonas, TB
30
Atypical pneumonia associations ``` Mycoplasma chlamydia pneumonia (age, assoc clinical finding) ``` Legionella (source, assoc clincal findings, transmission pearl, sputum smear result)
Mycoplasma: young adults, extra pulmonary findings (see below)\* chlamydia pneumonia: infants and young adults, conjunctivitis Legionella: water, air conditioning, older man, no person to person spread, sputum smear negative) \*Guillain-Barré, encephalitis, hemolysis, cold agglutinins, bullous myringitis, erythema multiforme
31
Really atypical pneumonia Fungal (3), CXR findings Zoonotic (2) and sources
Cocci (Southwest), Histo (Miss river valley), Blasto (SE US); CXR: hilar adenopathy, patchy infiltrates Q fever (Coxiella Burnetii - Vets, farmers -\> sheep, goats, cattle); Hepatitis and endocarditis Psittacosis: Bird handler; brady, sepsis, low WBC
32
Pneumonia Gram stains
33
Pneumonia treatment by class outpatient, young, healthy inpatient, older, sicker healthcare associated
outpatient, young, healthy: macrolide inpatient, older, sicker: macrolide plus cephalosporin or quinolone healthcare associated: antipseudomonal penicillin, carbopenem or aminoglycoside
34
Uncommon pneumonias 1. Southwest US, rodent excreta; tx 2. fleas/rodents, squirrels; tx 3. Inhaled bioagent; spread, classic xray, tx (3)
1. Hantavirus, supportive therapy only 2. Yersinia pestis (plague); doxycycline, fluoroquinolone, aminoglycoside 3. Anthrax; no person-to-person spread, prominent mediastinum due to hemorrhagic mediastinitis; doxycycline, FQ, PCN
35
Pneumonia in HIV, common types ## Footnote Bacterial: Mycobacterial: Parasitic: Viruses: Fungal:
Bacterial: Most common, Same pathogens as non-AIDS Mycobacterial: TB, Mycobacterium avium complex (MAC) Parasitic: Toxoplasmosis Viruses: CMV, HSV Fungal: PCP Often disseminated Cryptococcosis, histoplasmosis, aspergillosis, candidiasis **Noninfectious**: Kaposi's sarcoma and non-Hodgkin's lymphoma
36
Pneumonia and HIV by CD4 \< 200 (2), dx pearl, tx (3 + 1) \< 50 (3)
\< 200: PCP (elevated LDH, sens not spec), TB \< 50: CMV, MAC, fungal, PCP tx: Septra, Pentamadine, Dapsone, steroids pO2 \< 70 or A-a gradient \> 35
37
38
Foreign body aspiration method to detect occult aspiration
Decubitus film showing failure of affected lung to deflate when mainstem bronchus is blocked
39
Aspiration PNA abx timing
Hold antibiotics until febrile to avoid selecting out resistant organisms
40
Tuberculosis location-primary location - reactivation progression within and after two years rate sensitivity of AFB smear
Right lower or middle lobe upper lobe, can be cavitary 5% for each x-ray shows cavitary right upper lobe lesion sensitivity: only 60%
41
Miliary TB from hematogenous spread
42
Tuberculosis isoniazid side effects (2) positive TB skin test
Hepatitis and peripheral neuropathy 5 mm: high-risk (HIV, close contacts, chest x-ray changes, immunosuppressed) 10 mm: medium risk (immigration less than five years from high-risk area, IVDU, working high-risk setting, comorbidities, children \< 5 etc) 15 mm: low risk
43
Sarcoidosis classic quadrad (4) of findings Treat flares/complications with
Bilateral hilar adenopathy, pulmonary infiltrates, ocular and skin lesions Tx: steroids
44
Mediastinal masses anterior - most common and mnemonic (5)
Bronchogenic cancer ## Footnote •Mass in anterior mediastinum: five “T”s –Thymoma (consider myasthenia gravis) –Thyroid (retrosternal) –Teratoma (teeth, hair, etc.) –T cell lymphoma –"Terrible“ (carcinoma)
45
Hemoptysis most common cause definition of massive Tx massive: Breathing (2), definitive (2)
most common cause: bronchitis definition of massive: \> 600 ML 24 hours were 50 ML in single cough Breathing (2): decubitus with bleeding side down, selective mainstem intubation definitive (2): surgery, bronchial artery embolization, bronchoscopy
46
Pneumomediastinum, often benign but In trauma consider non-trauma consider eponym for physical finding
In trauma consider: tracheobronchial injury non-trauma consider: Boerhaave's eponym for physical finding: Hamman's crunch synchronus with heart sounds
47
Pneumomediastinum also seen on lateral neck film just anterior to vertebral bodies
48
Pleural effusion transudative versus exudative Transudate lab findings (3)
transudative: increased hydrostatic or decreased oncotic pressure (eg CHF, cirrhosis) exudative: neoplastic, inflammatory, infectious Transudate lab findings: low protein (\<3 mg/dL), LDH \< 200, pleural:serum prot \< 0.5
49
Pulmonary embolism Westermark's Sign EKG signs of right ventricular strain (6) D-dimer ELISA vs Latex agluttination
Westermark's Sign: relative oligemia (decreased vascular lung markings) distal to large PE ELISA superior RV strain: Inverted T waves V1-V4 S1Q3T3 RBBB P pulmonale Right axis deviation Tachycardia
50
Pulmonary embolism Treatment options (4)
Heparin: 80u/kg bolus, followed by 18u/hour infusion IVC Filter (Greenfield): when anticoagulation is contraindicated Fibrinolytics (tPA): Now indicated only for PE causing shock with RV strain Surgical embolectomy: Rarely indicated, needs bypass
51
Tracheostomy respiratory distress steps (3) Bleeding steps (life threatening bleed can come from innominate artery)
1. Remove inner cannula, suction, irrigate with saline 2. Replace entire trach (over catheter as needed) 3. Look for other cause Bleeding: hyperinflation of balloon with levering of tube posteriorly; inntubate patient, place finger in trach hole (but not in trachea) and apply posterior pressure

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