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Flashcards in Pulmonary Emergencies 1 Deck (40):

Upper airway obstructions caused by? 3

1. Foreign body
2. Tongue
3. Swelling/edema


Upper airway obstruction: assessment

1. Air movement- Stridor or snoring
2. Ability to talk and/or swallow- Drooling, muffled voice
3. Associated shortness of breath
4. Vital signs needs to include an O2 saturation
5. Is patient stable or unstable?


Upper airway obstruction:

1. Foreign body
2. Retropharyngeal abscess
3. Angioedema
4. Head and neck trauma
5. Swelling/edema from inhalation injuries
6. Epiglottitis, croup,
7. tonsillitis,
8. peritonsillar abscess,
9. Ludwig’s angina (will all be covered in the ENT section)


1. If you hear noise coming out of the mouth or nose what kind of obstruction is it?

2. Complete obstruction of the upper airway?

3. What question should you ask/what should you prepare for?

1. incomplete. stridor

2. Heimlich, Magill forceps

3. Do they need a cricothyroidotomy?


Retropharyngeal abcess is a serious emergency. It can spread where?

Retropharyngeal space extends from where to where?

Can spread to the mediastinum

the base of the skull to the tracheal bifurcation


Retropharyngeal abscess
1. Etiology in children?
2. In adults? 3

1. Etiology…children
-Usually from a lymph node that drains the head and neck

2. Etiology… adults
-Penetrating trauma (chicken bones, etc)
-From an infection in the mouth/teeth
-Lymph nodes that drain the head and neck


What will you see on Xray for the retropharyngeal abscess?

expansion of the prevertebral soft tissues


Retropharyngeal abscess signs and symptoms

1. Fever
2. Dysphagia
3. Neck pain
4. Limitation of cervical motion
5. Cervical lymphadenopathy
6. Sore throat
7. Poor oral intake
8. Muffled voice
9. Respiratory distress
10. Stridor more likely in children
11. Inflammatory torticollis


Work up: Retropharyngeal abscess

1. Lateral soft tissue Xray of the neck during inspiration
2. CT scan of the neck is the “gold standard”


Treatment Retropharyngeal abscess 3

1. Immediate ENT consult
2. Treatment is surgical incision and drainage
3. IV hydration and IV antibiotics to be started in the emergency room


Treatment of retropharyngeal abscess: Abx? 2

1. Clindamycin…. adult dose 600-900 mg IV q 8 h
2. or ampicillin-sulbactam (Unasyn) adult dose 1500-3000 mg q 6 h


Retropharyngeal abscess: complications

1. Extension of the infection into the mediastinum
-Pleural or pericardial effusion
2. Upper airway asphyxia
3. Sudden rupture


If there was a sudden rupture of the retropharngeal abcess what could happen?

1. Aspiration pneumonia
2. Widespread infection


1. Swelling where? 2
2. Swelling is described as? 2
3. Can occur in association with? 3

-Subdermal or
-submucosal swelling
2. Swelling is
-diffuse and
3. Can occur
-in isolation,
-with urticaria, or as
-a component of anaphylaxis


management? 2

1. Rapid initial assessment of airway and close monitoring.
2. Intubation or a surgical airway may be necessary.


1. Affects where? 5

2. Often symmetric or asymmetric?

1. Affects the
-face, lips, mouth,
-throat, larynx,
-genitalia and
-possibly the bowel (colicky abdominal pain)

2. Often asymmetric swelling


Angioedema: Etiology
1. Mast cell mediated responds to? 3

2. Bradykinin mediated is secondary to what? 2

1. Responds to
-glucocorticoids and

2. Secondary to
-ACE-inhibitors or
-Hereditary angioedema


Angioedema: Treatment (allergic)

1. Intubate immediately if any signs of respiratory distress

Mast cell mediated (allergic):
2. epinephrine 0.3 mg IM
3. glucocorticoids (Methylprednisolone 60-80mg IV or oral prednisone 40mg)
4. diphenhydramine 25-50mg IV


1. Angioedema: treatment ACE inhibitor induced? 2

2. If swelling is severe or no improvement in 24h? 3

-Intubate immediately if signs of respiratory distress
-Discontinue the offending drug (ACEI). Usually symptoms resolve in 24 -72 hours.

-glucocorticoids (? Benefit)
-C1 inhibitor therapy

(recombinant C1 inhibitor obtained from the milk of transgenic rabbits or from donated blood/fresh frozen plasma


Hereditary Angioedema: treatment

1. Intubate immediately if any signs of respiratory distress
2. Bradykinin receptor antagonist is second line therapy if C1 inhibitor concentrate not available from fresh frozen plasma or Ruconest.


Define anaphylaxis?

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


Anaphylaxis: presentation

1. Sudden onset generalized urticaria (hives) (10-20% will have no skin symptoms)
2. Angioedema
3. Flushing
4. Pruritus
5 Hypotension


1. Anaphylaxis: Treatment

2. Dosing?

1. Epinephrine. All other treatments are supportive and do not reverse the process.

2. Adults: 0.3-0.5 mg IM
Children: 0.1 mg/kg with a max dose of 0.5 mg
Give q 5-15 min up to 3 doses


Anaphylaxis: Airway management
1. Immediate assessment for what?
2. Immediate intubation? 2

3. May require what?

1. Immediate assessment for
-stridor and
-difficulty breathing in general.

2. Immediate intubation if
-marked stridor or
-respiratory arrest.

3. May require a surgical airway.


Anaphylaxis: Overview of treatment

1. Assess airway/do they need to be intubated?
2. Simultaneously give IM epinephrine and do everything else
3. O2 via nonrebreather (if they have a patent airway)
4. Need two large bore IV access sites
5. Normal saline rapid bolus via IV (1-2 L initially but may need more) 20 ml/kg in kids
6. Consider albuterol nebulizer, H1 blocker, H2 blocker, methylprednisolone


Consider what supplemental medications with anaphylaxis? 4

1. albuterol nebulizer,
2. H1 blocker,
3. H2 blocker,
4. methylprednisolone


1. Epi dose?
2. Which H1 blocker?
3. Which H2 blocker?
4. Wheich steriod?
5. Dose of nebulizer?
6. What for shock may be necessary?

1. Epinephrine 0.3-0.5 mg IM q 5-15 min X3 doses if needed
2. H1 blocker: diphenhydramine (Benadryl) 50mg IV
3. H2 blocker: ranitidine 50mg IV
4. Glucocorticoid: Solu-medrol 125mg IV
5. Albuterol nebulizer 2.5mg
6. Vasopressors for shock may be necessary


Head and neck trauma: assessment
What do the following sounds indicate?
1. Gurgling?
2. Snoring?
3. Stridor? 2
4. Wheezing?

1. Gurgling
-Pooling of liquids in the oral cavity or hypopharynx

2. Snoring
-Partial airway obstruction at the pharyngeal level from the tongue

3. Stridor
-Inspiratory: obstruction at the level of the larynx
-Expiratory: obstruction at the level of the trachea

4. Wheezing
Narrowing of lower airways


Head and neck trauma
1. Secure the airway while simultaneously protecting what?

2. What can often clear the airway?

3. When may need to displace the tongue forward to maintain a patent airway?

1. the brain and c-spine from further injury.

2. Jaw thrust maneuver and suctioning

3. Mandibular fractures


Head and neck trauma: secure the airway
1. Avoid what with midface trauma to avoid communication with the cranium?

2. Rapid sequence intubation vs. intubation without paralytics
How hard are they to adequately bag-valve mask ventilate?
-Need to prep for what prior to RSI?
-If hypopharynx is intact what will usually suffice for backup?

1. nasotracheal intubation

- LMA suffice for back up?


Stupor and coma
1. Inability to protect airway due to what?
2. What are our options here?

1. lack of gag reflex
2. Oropharyngeal airway vs. intubation


Define stupor?

Define Coma?

1. Stupor is the lack of critical cognitive function and level of consciousness wherein a sufferer is almost entirely unresponsive and only responds to base stimuli such as pain.

2. Coma is a state of unconsciousness lasting more than six hours, in which a person: cannot be awakened; fails to respond normally to painful stimuli, light, or sound; lacks a normal sleep-wake cycle; and does not initiate voluntary actions.


1. What is it?
2. Can occur how? 2

1. Accumulation of air in the pleural space
2. Can be spontaneous or trauma induced


What is a spontaneous pneumothorax?

Pneumothorax that occurs without a precipitating event in a person without lung disease.


Spontaneous pneumothorax
Risk factors? 7

1. men
2. ages 20-40
3. thin build
4. smokers
5. family history
6. Marfan syndrome
7. prior episode has recurrence rate is 25-54%


Spontaneous pneumothorax

1. Sudden onset of dyspnea and pleuritic chest pain
2. Often occurs at rest


Pneumothorax: Physical exam

1. Decreased chest excursion
2. Decreased breath sounds on the affected side
3. Hyperresonant to percussion
4. Possible subcutaneous emphysema
5. Hypoxemia


Suspect a tension pneumothorax if?

1. Labored breathing
2. Tachycardia
3. Hypotension
4. Tracheal shift
5. JVD


Pneumothorax: treatment

1. Supplemental O2 (before and after decompression)

2. Needle decompression followed by chest tube placement (unstable)

3. or primary treatment with chest tube

Choice above depends on how stable the patient is


Decompression of a pneumothorax is done where?

1. at the 2nd or 3rd ICS at the midclavicular line

2. at the 5th ICS at the anterior axillary line