Pulmonary Emergencies Flashcards Preview

Emergency Medicine > Pulmonary Emergencies > Flashcards

Flashcards in Pulmonary Emergencies Deck (98):
1

Causes of Upper Airway Obstruction

Foreign body
Tongue
Swelling/edema

2

Upper Airway Obstruction Etiology

Foreign body
Retropharyngeal abscess
Angioedema
Head and neck trauma
Swelling/edema from inhalation injuries
Epiglottitis
Croup
Tonsillitis
Peritonsillar abscess
Ludwig's angina

3

Types of Foreign Body Obstruction

Incomplete
Complete

4

Where does the retropharyngeal space extend from and go to?

Base of the skull to the tracheal bifurcation

5

Etiology of Retropharyngeal Abscess in Children

Lymph node that drains the head and neck

6

Etiology of Retropharyngeal Abscess in Adults

Penetrating trauma
Infection in the mouth/teeth
Lymph nodes that drain the head and neck

7

Signs and Symptoms of a Retropharyngeal Abscess

Fever
Dysphagia
Neck pain
Limitation of cervical motion
Cervical lymphadenopathy
Sore throat
Poor oral intake
Muffled voice
Respiratory distress
Stridor (children)
Inflammatory torticollis

8

Work Up of Retropharyngeal Abscess

Lateral soft tissue X-ray of the neck during inspiration
CT scan of the neck: "gold standard"

9

Treatment of Retropharyngeal Abscesses

Immediate ENT consult
Surgical I&D
IV hydration
IV antibiotics

10

Antibiotics for a Retropharyngeal Abscess

Clindamycin
Ampicillin-sulbactam (Unasyn)

11

Complications of a Retropharyngeal Abscess

Extension of infection into mediastinum
Pleural or pericardial effusion
Upper airway asphyxia
Sudden Rupture: aspiration pneumonia or widespread infection

12

Define Angioedema

Subdermal or submucosal swelling

13

Describe the Swelling in Angioedema

Diffuse
Non-pitting

14

Assessment of Angioedema

Rapid assessment of airway
Close monitoring

15

What areas of the body does angioedema generally affect?

Face
Lips
Mouth
Throat
Larynx
Extremities
Genitalia
Bowel

16

Etiology of Angioedema

Mast cell mediated
Bradykinin mediated

17

What medications does mast cell mediated angioedema respond to?

Epinephrine
Glucocorticoids
Antihistamines

18

What conditions or medications does bradykinin mediated angioedema occur secondary to?

ACE-inhibitors
Hereditary angioedema

19

Treatment of Allergic Angioedema

Intubation if signs of respiratory distress
Epinephrine (0.3 mg IM)
Glucocorticoids
Diphenhydramine (25-50 mg IV)

20

Treatment of ACE Inhibitor Induced Angioedema

Intubation if signs of respiratory distress
Discontinue offending drug
If severe or no improvement in 24 hours: antihistamines, glucocorticoids, C1 inhibitor therapy

21

Treatment of Hereditary Angioedema

Intubation if signs of respiratory distress
C1 inhibitor if available
Bradykinin receptor antagonist

22

Define Anaphylaxis

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

23

Presentation of Anaphylaxis

Sudden onset urticaria
Angioedema
Flushing
Pruritus
Hypotension

24

Treatment of Anaphylaxis

Epinephrine

25

Airway Management in Anaphylaxis

Immediate assessment for wheezing, stridor, and difficulty breathing
Intubation if marked stridor or respiratory arrest

26

Treatment of Anaphylaxis

Assess airway
IM epinephrine
O2 via nonrebreather (patent airway)
2 large bore IVs
NS rapid bolus via IV (1-2L)
Consider: albuterol nebulizer, H1 blocker, H2 blocker, methylprednisolone

27

Usually Medications Given in Anaphylaxis

Epinephrine
H1 blocker: diphenhydramine
H2 blocker: ranitidine
Glucocorticoid: solu-medrol
Albuterol nebulizer
Possible vasopressors

28

Possible Assessment Findings in Head and Neck Trauma

Gurgling
Snoring
Stridor
Wheezing

29

Define Gurgling

Pooling of liquids in the oral cavity or hypopharynx

30

Define Snoring

Partial airway obstruction at the pharyngeal level from the tongue

31

Define Stridor

Inspiratory: obstruction at the level of the larynx
Expiratory: obstruction at the level of the trachea

32

Define Wheezing

Narrowing of lower airways

33

Important Aspect in Head and Neck Trauma

Securing the airway
Avoid nasotracheal intubation

34

Stupor/Coma and Airway

Inability to protect airway due to lack of gag reflex

35

Define Stupor

Lack of critical cognitive function and level of consciousness wherein a sufferer is almost entirely unresponsive and only response to base stimuli such as pain

36

Define Coma

State of unconsciousness lasting more than 6 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

37

Define Pneumothorax

Accumulation of air in the pleural space

38

Describe a Spontaneous Pneumothorax

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

39

Risk Factors for a Spontaneous Pneumothorax

Men
Age: 20-40
Thin build
Smokers
Family history
Marfan syndrome
Prior episode

40

Presentation of a Spontaneous Pneumothorax

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

41

Physical Exam Findings in Pneumothorax

Decreased chest excursion
Decreased breath sounds on the affected side
Hyperresonant to percussion
Possible subQ emphysema
Hypoxemia
Suspicion of tension pneumothorax

42

When should one suspect a tension pneumothorax?

Labored breathing
Tachycardia
Hypotension
Tracheal shift
JVD

43

Treatment of Pneumothorax

Supplemental O2
Needle decompression
Chest tube placement

44

Presentation of Acute Pulmonary Edema

Dyspnea
Frothy pink sputum
Pedal edema
Ascites
Rales
Wheezing
HTN
Hypoxemia
Restlessness
Tachycardia
Look ill
Cold sweat

45

Types of Acute Pulmonary Edema

Cardiogenic
Non-cardiogenic

46

Acute Causes of Cardiogenic Pulmonary Edema

Ischemia
Acute severe mitral regurgitation
Acute aortic regurgitation
Hypertensive crisis secondary to bilateral renal artery stenosis
Stress induced cardiomyopathy

47

Chronic Causes of Cardiogenic Pulmonary Edema

Decompensated systolic CHF
Decompensated diastolic CHF
Left ventricular outflow tract (LVOT) obstruction
Valvular heart disease

48

Noncardiogenic Pulmonary Edema

ARDS
Altitude
Neurogenic
Narcotic overdose
Pulmonary embolism
Eclampsia
Transfusion related injury
Salicylate overdose

49

Etiology of ARDS

Sepsis
Acute pulmonary infection
Trauma
Inhaled toxins
DIC
Shock lung
Freebase cocaine smoking
Post CABG
Inhalation of high concentrations of O2
Acute radiation pneumonitis

50

Treatment of Cardiogenic Acute Pulmonary Edema

O2
Treat underlying cause
Ischemia
Valvular disease
Treat arrhythmias

51

Treatment of Noncardiogenic Acute Pulmonary Edema

O2
Treat underlying cause
Likely intubation and mechanical ventilation with PEEP
Diuretics

52

Treatment of Generalized Acute Pulmonary Edema

Assess the airway and stability of the patient
Furosemide (Lasix) if hemodynamically stable
Supplemental O2
Treat underlying cause

53

Pathophysiology of Asthma

Inflammation of the airways with an abnormal accumulation 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

54

Things to Beware of During Assessment of Acute Asthma

Use of accessory muscles of respiration
Fragmented speech
Orthopnea
Diaphoresis
Agitation
Low blood pressure
Severe symptoms that fail to improve

55

Findings Demonstrating Impending Respiratory Failure in Acute Asthma

Inability to maintain respiratory effort and rate
Cyanosis
Depressed mental status
Severe hypoxemia despite high flow O2 via non-rebreather

56

Assessment of Acute Asthma

Measure peak flow
Supplemental O2
Establish IV access
Frequent reassessment
ABGs & CXR not useful initially

57

How does peak flow help in the assessment of an acute asthma patient?

Provides an objective measurement as to the severity of airflow obstruction

58

When should you measure peak flow?

Before and after each nebulizer or MDI treatment

59

Medical Therapy for Acute Asthma

Albuterol
Ipratropium bromide
Methylprednisolone
Magnesium sulfate
Epinephrine
Terbutaline

60

Function of Albuterol

Bronchodilator

61

Function of Ipratropium Bromide

Bronchodilator
With the albuterol = Duoneb

62

Function of Methylprednisolone (Solu Medrol)

Decreases airway inflammation

63

When is magnesium sulfate given in an acute asthma patient?

Life threatening exacerbations that remains ever after 1 hour of intense bronchodilator therapy

64

When is epinephrine given in an acute asthma patient?

Suspected anaphylactic reaction or unable to use inhaled bronchodilators

65

When is terbutaline given in an acute asthma patient?

Severe asthma unresponsive to standard therapy

66

What is a COPD exacerbation generally precipitated by?

Viral or bacterial infection

67

Define COPD Exacerbation

Increase or change in character of usual symptoms of dyspnea, cough, or sputum production

68

Work Up of a COPD Exacerbation

O2 saturation
ABG: severe
CXR
CBC (+/-)
BMP (+/-)
BNP (+/-)
EKG

69

What is a CXR assessing for in COPD exacerbations?

Pneumonia
Acute heart failure
Pneumothorax

70

Pharmacotherapy for COPD Exacerbation

Supplemental O2
Solumedrol (methylprednisolone)
Antibiotics: cover pseudomonas
Inhaled bronchodilators

71

When would you consider hospital admission for a COPD exacerbation?

Symptoms severe enough to prevent ADLs and IADLs
Failure to respond to initial therapy
High risk co-morbidities
Worsening hypoxemia

72

What are high risk co-morbidities in a COPD exacerbation?

Pneumonia
CHF
Arrhythmia
Liver failure
Kidney failure
DM

73

What is the treatment of impending respiratory failure in a COPD exacerbation?

Intubation
Non-invasive positive pressure ventilation

74

Define Pulmonary Embolism

Obstruction of the pulmonary artery or branches with clot, tumor, air, or fat

75

Signs and Symptoms of Pulmonary Embolism

Dyspnea
Tachypnea
Cough
Hemoptysis
Syncope
Lower extremity edema
Cyanosis
Diaphoresis
Hypotension
Rales (+/-)
Lower extremity pain or erythema

76

Risk Factors for Establishing a Pulmonary Embolism

Pregnancy
Obesity
Prolonged immobilization
Hormones: BCPs, HRT, SERMs
Cancer
Trauma
Recent joint replacement surgery
History of DVT
Autoimmune disease
HTN
Smoking
CHF

77

Wells Criteria for Pulmonary Embolism

Clinical Signs and Symptoms of DVT
PE Is #1 Diagnosis, or Equally Likely
Heart Rate > 100
Immobilization at least 3 days, or surgery in the Previous 4 weeks
Previous, objectively diagnosed PE or DVT
Hemoptysis
Malignancy w/ treatment within 6 mo, or palliative

78

Work Up of Pulmonary Embolism

CTA of the chest with PE protocol
CXR
EKG: sinus tach
Echo +/-
V/Q scan
D-dimer
Doppler US of LE

79

What changes can you see on lead I of an EKG for a pulmonary embolus?

S-waves

80

What changes can you see on lead III of an EKG for a pulmonary embolus?

Q-waves
Inverted T-waves

81

Treatment and Stabilization of an Acute PE

Supplemental O2
Hypotensive: fluid bolus, vasopressors

82

What vasopressors are used to treat an acute PE?

Norepinephrine
Dopamine
Epinephrine
Dobutamine + norepinephrine

83

Pharmacologic Treatment of Acute PE

Unfractionated heparin (UFH)
Low molecular weight heparin (LMWH)
Fondaparinux

84

Treatment of Acute PE

Vitamin K agonist should be started same day as anticoagulant therapy
Continue Lovenox until INR is 2.0
Thrombolytics??

85

Signs and Symptoms of Pneumonia

Cough
Fever
Chills
Pleuritic chest pain
Dyspnea
Sputum production
Mental status changes
GI symptoms (N/V/D)
Tachypnea
Tachycardia
Hypoxia
Rales, rhonchi, or decreased in area of consolidation

86

Work Up of Pneumonia

PA and lateral CXR
CBC, CMP
Blood cultures
Sputum for gram stain and culture
Pneumococcal and Legionella urine antibody tests

87

Hospital Admission Pneumonic's for Pneumonia

PSI
CURB-65

88

Components of a PSI Score

Age
Gender
Nursing home resident
Neoplastic disease
Liver disease history
CHF history
Cerebrovascular disease history
Renal disease history
Altered mental status
RR 29+
SBP less than 90 mmHg
Temp: less than 35 or 39.9+
Pulse: 124+
pH: less than 7.35
BUN: 29+
Sodium: less than 130
Glucose: 249+
Hematocrit: less than 30%
pO2: less than 60 mmHg
Pleural effusion

89

Components of CURB-65

C: confusion
U: urea (BUN >19 mg/dL)
R: RR >30
B: SBP less than 90 or DBP less than 60
65: 65+ years old

90

Treatment of Pneumonia

Supplemental O2
Intubation or NiPPV if respiratory failure
Antibiotics
Fluids
Antipyretics
Albuterol nebulizer (+/-)
Incentive spirometry

91

Most Likely Pneumonia Pathogen

Strep pneumo

92

Non-ICU Hospital Admission Pneumonia Pathogens

Strep pneumo
Respiratory viruses
M. pneumoniae
H. flu
C. pneumoniae
Legionella

93

Antibiotics for Non-ICU Pneumonia Patients

Respiratory fluroquinolone OR antipneumococcal beta-lactam
PLUS
Macrolide

94

Examples of Respiratory Fluroquinolones

Levofloxacin
Moxifloxacin
Gemifloxacin

95

Examples of Antipneumococcal Beta-Lactam

Cefotaxime
Ceftriaxone
Ampicllin-sulbactam (Unasyn)

96

Examples of Macrolides

Azithromycin
Clarithromycin
Erythromycin

97

Pathogens for Patients Requiring ICU Admission for Pneumonia

S. pneumoniae
Legionella
Gram-negative bacilli
Staph aureus
Consider MRSA

98

Antibiotics for ICU Pneumonia

Antipneumococcal beta-lactam + azithromycin
Antipneumococcal beta-lactam + respiratory fluoroquinolone
Penicillin allergy: respiratory fluoroquinolone + aztreonam