Pulmonary Emergencies Flashcards
(98 cards)
1
Q
Causes of Upper Airway Obstruction
A
Foreign body
Tongue
Swelling/edema
2
Q
Upper Airway Obstruction Etiology
A
Foreign body Retropharyngeal abscess Angioedema Head and neck trauma Swelling/edema from inhalation injuries Epiglottitis Croup Tonsillitis Peritonsillar abscess Ludwig's angina
3
Q
Types of Foreign Body Obstruction
A
Incomplete
Complete
4
Q
Where does the retropharyngeal space extend from and go to?
A
Base of the skull to the tracheal bifurcation
5
Q
Etiology of Retropharyngeal Abscess in Children
A
Lymph node that drains the head and neck
6
Q
Etiology of Retropharyngeal Abscess in Adults
A
Penetrating trauma
Infection in the mouth/teeth
Lymph nodes that drain the head and neck
7
Q
Signs and Symptoms of a Retropharyngeal Abscess
A
Fever Dysphagia Neck pain Limitation of cervical motion Cervical lymphadenopathy Sore throat Poor oral intake Muffled voice Respiratory distress Stridor (children) Inflammatory torticollis
8
Q
Work Up of Retropharyngeal Abscess
A
Lateral soft tissue X-ray of the neck during inspiration
CT scan of the neck: “gold standard”
9
Q
Treatment of Retropharyngeal Abscesses
A
Immediate ENT consult
Surgical I&D
IV hydration
IV antibiotics
10
Q
Antibiotics for a Retropharyngeal Abscess
A
Clindamycin
Ampicillin-sulbactam (Unasyn)
11
Q
Complications of a Retropharyngeal Abscess
A
Extension of infection into mediastinum
Pleural or pericardial effusion
Upper airway asphyxia
Sudden Rupture: aspiration pneumonia or widespread infection
12
Q
Define Angioedema
A
Subdermal or submucosal swelling
13
Q
Describe the Swelling in Angioedema
A
Diffuse
Non-pitting
14
Q
Assessment of Angioedema
A
Rapid assessment of airway
Close monitoring
15
Q
What areas of the body does angioedema generally affect?
A
Face Lips Mouth Throat Larynx Extremities Genitalia Bowel
16
Q
Etiology of Angioedema
A
Mast cell mediated
Bradykinin mediated
17
Q
What medications does mast cell mediated angioedema respond to?
A
Epinephrine
Glucocorticoids
Antihistamines
18
Q
What conditions or medications does bradykinin mediated angioedema occur secondary to?
A
ACE-inhibitors
Hereditary angioedema
19
Q
Treatment of Allergic Angioedema
A
Intubation if signs of respiratory distress
Epinephrine (0.3 mg IM)
Glucocorticoids
Diphenhydramine (25-50 mg IV)
20
Q
Treatment of ACE Inhibitor Induced Angioedema
A
Intubation if signs of respiratory distress
Discontinue offending drug
If severe or no improvement in 24 hours: antihistamines, glucocorticoids, C1 inhibitor therapy
21
Q
Treatment of Hereditary Angioedema
A
Intubation if signs of respiratory distress
C1 inhibitor if available
Bradykinin receptor antagonist
22
Q
Define Anaphylaxis
A
Acute, potentially lethal, multi system syndrome from the sudden release of mast cells and basophils into the circulation
23
Q
Presentation of Anaphylaxis
A
Sudden onset urticaria Angioedema Flushing Pruritus Hypotension
24
Q
Treatment of Anaphylaxis
A
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
