Respiratory Emergencies Flashcards
(108 cards)
1
Q
With reference to breath sounds what does wheezing sound like?
A
Musical, whistling noise, high-pitched
2
Q
With reference to breath sounds what do crackles or rails sound like?
A
Popping noises that are non-musical
3
Q
With reference to breath sounds what do rhonchi sound like?
A
Snoring sound, low pitch
4
Q
With reference to breath sounds what does pleural friction rub sound like?
A
Grating sound with respirations
5
Q
What is the V-Q relationship?
A
The open Alveolus and the open capillary are necessary in order for diffusion of gases to occur. When there is a problem with either of these structures, blood is not oxygenated
6
Q
Normal arterial blood gases:
A
PH = 7.35 to 7.45
PA02 = 80 to 100
PACO2 = 35 to 45 HCO3 equals 22 to 26
BE = +/- 2
7
Q
What happens to your pH during acidosis?
A
Your pH decreases
8
Q
What happens to PCO2 and HCO3 during respiratory acidosis?
A
PCO2 is increased
HCO3 is normal
9
Q
What happens to PCO2 and HCO3 during metabolic acidosis?
A
PCO2 is normal
HCO3 is decreased
10
Q
What happens to your pH during alkalosis?
A
PH is increased
11
Q
What happens to PCO2 and HCO3 during respiratory alkalosis?
A
PCO2 is decreased
HCO3 is normal
12
Q
What happens to PCO2 and HCO3 during metabolic alkalosis?
A
PCO two is normal
HCO3 is increased
13
Q
What are some other names for acute respiratory distress syndrome (ARDS)?
A
Hyaline membrane disease
Wet loan
Posttraumatic pulmonary insufficiency
DeNang lung
Shock long
Acute lung injury (ALI)
pulmonary contusion
14
Q
What is the mortality rate of ARDS?
A
40 to 70%
15
Q
What are the Etiologies of acute respiratory distress syndrome that are related to direct pulmonary injury?
A
Pneumonia
Embolism
Aspiration
Inhalation
Prolonged exposure to oxygen
High altitude pulmonary edema
Lung contusions
16
Q
What are the Etiologies of acute respiratory distress syndrome that are related to systemic illnesses?
A
Sepsis
Disseminated intravascular coagulation
Pancreatitis
Uremia
Anaphylaxis
Drug overdose
Eclampsia
Radiation therapy
Shock
17
Q
What are the etiologies of acute respiratory distress syndrome that are related to trauma?
A
Multisystem trauma
Massive blood transfusions
18
Q
Possible causes of respiratory alkalosis:
A
Acute asthma
Hepatic failure
Pregnancy
Pneumonia
Lung disease
Pulmonary disease
Anxiety
Aspirin toxicity
Metabolic acidosis
CNS disease
Sepsis
19
Q
Symptoms of respiratory alkalosis:
A
Deep rapid breathing
Lightheadedness
Dizziness
Agitation
Carpopedal spasm
Twitching
Tetany
Muscle weakness
20
Q
Treatment for respiratory alkalosis:
A
Correct underline cause
Oxygen for acute episode of hypoxemia
Paper bag
Adjust tidal volume and minute volume (prevent hyperventilation)
21
Q
Possible causes of respiratory acidosis:
A
Hyperventilation
CNS trauma
Cardiac arrest
Sleep apnea
Ventilator therapy
Airway obstruction
ARDS
Myasthenia gravis
Guillian Barre
Pneumothorax
Pneumonia
pulmonary edema
22
Q
Symptoms of respiratory acidosis:
A
Restlessness
Confusion
Somnolence
Tremor
Coma
Headache
Papilledema
Tachycardia
Hypoxemia
23
Q
Treatment for respiratory acidosis:
A
Treat underlying cause
24
Q
 Possible causes of metabolic alkalosis:
A
Due to acid loss:
Vomiting
NG tube in place
Lavage
Fistula‘s
Massive blood transfusions
Cushing’s disease
Due to bicarbonate retention:
Intake of bicarbonate of soda
IV fluids with bicarbonate/lactate
Alteration in ECF electrolytes
Decreased potassium
25
Symptoms of Metabolic Alkalosis:
Decreased Cerebral Perfusion
Irritability
Picking at clothing
Twitching
Confusion
Decreased Potassium
Dysrhythmias
Decreased blood flow
Carpopedal spasm
Impending tetany
26
Treatment of Metabolic Alkalosis:
Replace losses with potassium and normal saline.
Stop diuretics.
Acetazolamide to increase excretion of bicarbonate.
27
Causes of Metabolic Acidosis:
Increased Acids:
DKA
Lactic Acidosis
Malnutrition
Starvation
Chronic Alcoholism
Bicarbonate Loss:
Diarrhea
Intestinal suction
Renal failure
Hyperaldosteronism
Aspirin intoxication
28
Symptoms of Metabolic Acidosis:
Headache
Malaise
Lethargy
CNS depression
Kussmaul breathing
Nausea
Vomiting
Warm skin
Flushed
29
Treatment for Metabolic Acidosis:
Na bicarbonate
Monitor electrolytes
IV administration
Mechanical ventilation
Antibiotics
Antidiarrheals
30
Characteristic Findings of ARDS:
Hypoxia
Dyspnea
Diffuse Bilateral Infiltrates
31
Pathophysiology of ARDS:
Increased permeability of alveolar/capillary membrane occurs from the release of chemical mediators, alveolar macrophages, and vasoactive substances.
Decreasing surfactant causes decreased lung compliance.
Atelectasis occurs causing severe respiratory distress and failure.
32
Manifestations of ARDS:
Tachypnea
Tachycardia
Hypoxia
Hypotension
Respiratory Distress
Restlessness
Cyanosis
Crackles
Bilateral infiltrates - “fluffy/ground glass appearance”
33
Treatment of ARDS:
-Supportive care is provided with intubation and mechanical ventilation with the addition of PEEP to maintain gas exchange (high frequency jet ventilation may be used).
-Correct things that might cause a shift to the left.
-Fluid balance must be monitored closely with a foley in place.
-Treat temperature.
-Treat infections and use high level of infection control techniques.
-Maintain hemoglobin level of at least 12-15gm/dL and correct factors that might cause a shift to the left.
34
Describe Asthma:
-Reversible obstructive pulmonary disease with intermittent episodes of bronchospasm. Rapid assessment is mandatory.
-Lymphocytes produce IgE in response to an allergen which attaches to the MAST cells (basophils) in bronchial walls which in turn releases chemical mediators.
35
If Asthma is not controlled what can it turn into?
Status Asthmaticus
-does not respond to conventional therapy.
- may lead to respiratory arrest.
36
Manifestations of Asthma:
- Wheezing on inspiration/expiration.
- Wheezing may not be present.
- Prolonged expiratory phase.
- Respiratory distress.
- Tachycardia
- Restlessness
- Pallor
- Exhaustion
37
Signs of impending respiratory failure in an Asthma patient:
- Decreasing oxygen saturation.
- Decreasing respiratory effort.
- Decreasing LOC.
- Increasing retention of Carbon Dioxide.
- Cyanosis
- Use of accessory muscles.
- Absence of wheezing.
38
Treatment of Asthma:
- Bronchodilators
- Corticosteroids
- Magnesium/Heliox
- Fluids
- Possible Intubation
- Monitor due to potential cardiac dysrhythmias.
- Peak flow monitoring before and after nebulizer treatments. (Normal 250-300. 100 is bad)
- Monitor ABGs:
- Hypoxemia will be present -pO2 <80mm Hg.
- Most patients will be hypocapneic due to hyperventilation.
- Hypercapnia will develop as condition worsens.
- Hypercapnia will create respiratory acidosis.
- Metabolic acidosis will occur from anaerobic metabolism.
39
What is Acute Bronchitis?
Inflammatory process that is usually viral (can have secondary Bacterial).
40
Manifestations of Acute Bronchitis:
- Dyspnea
- Wheezing
- Cough
- fever
- Chest/back pain
- malaise
- prolonged expiratory phase
- Rhonchi
- Neck vein distinction with chronic bronchitis.
41
Treatment for Acute Bronchitis:
- Aerosol treatments
- Postural drainage
- Oral fluids
- Bronchodilators
- Corticosteroids
-Antibiotics if secondary infection
42
What is Bronchiolitis?
- Lower respiratory tract infection with inflammation of airways in children under the age of 2 years.
- 90% is caused by RSV.
- Profuse secretions produce cellular debris and fibrin from a necrotic response which obstructs the bronchioles and bronchi leading to air trapping, high resistance, and atelectasis.
43
Manifestations of bronchiolitis:
- URI symptoms
- poor feeding
- irritability
- tachycardia
- decreased O2
- cyanosis
- cough
- vomiting
- decreased sleep
- wheezing
- changes in LOC
- tachypnea
- depressed fontanelle
44
Treatment of Bronchiolitis:
- Observe closely for signs of respiratory failure/need for hospitalization
- Sats <90%
- Heart rate >200
- RR >70 consistently.
- grunting, head bobbing, retractions, nasal flaring, accessory muscle use.
- Oxygen
- Hydration
- May need intubation.
- Ribavirin - antiviral for RSV (may have bad side effects).
- Synagis - monoclonal antibodies (used for special pop. Shot q 30 days).
45
What is Chronic Obstructive Pulmonary Disease (COPD)?
Chronic and recurrent airflow obstruction which affects at lease 15 million Americans.
Is the second most common disability in the U.S.
2 types:
- Chronic Obstructive Bronchitis
- Emphysema
46
Describe Chronic Obstructive Bronchitis:
- Inflammation of bronchi which causes increased mucus production and chronic cough.
- Decreased ciliary function causes increased susceptibility to infections.
- Chronic Hypercapnia occurs with hypoxia becoming the respiratory stimulus.
47
What hereditary component causes Hereditary COPD?
Alpha 1 antitrypsan deficiency causes hereditary COPD (ex: 20 year old with COPD).
48
Describe Emphysema:
- Impeded expiration from:
- Permanent overdistention of alveoli
- alveolar wall destruction
- airway collapse
- decrease in elastic recoil
- Increased ventilatory dead space from the formation of air pockets.
- Decreased functional lung tissue also occurs from the air pockets.
49
Manifestations of Chronic Obstructive Bronchitis:
* Blue Bloater*
- Productive cough
- stocky build
- increased music production
- Normal respiratory rate
- Hypoxemia (that becomes stimulus to breath)
- Increased PaCO2
- Rhonchi
- Frequent infections
- Accessory muscle use
- peripheral edema
- Risk for PE/Polycythemia
-X-ray shows enlarged heart.
50
Manifestations of Emphysema:
*Pink Puffer*
- cough uncommon - not productive
- Thin/barrel chest
- Oxygenated blood - low cardia output
- tachypnea
- PaO2 normal or slightly decreased
- PaCO2 usually low until end stage
- wheezing
- distant heart sounds
- accessory muscle use
- leans forward while sitting
- pursed-lip breathing
- Lung overinflation and diaphragm low
51
Treatment for COPD:
- Suction
- Oxygen - do not withhold
- Bronchodilators
- Steroids
- Antibiotics
- Hydration
- Education
- Lung volume reduction surgery
52
What is Croup?
Laryngotracheobronchitis - subglottic.
53
What are the usual causes of Croup?
- Parainfluenza virus type 1
- Parainfluenza virus type 3
- Adenovirus
- RSV
- Influenza A
54
What are the characteristics of Croup?
- Barking cough
- Hoarse voice
- Low grade fever
- Inspiratory strider
- Respiratory distress
- *Steeple sign on x-ray (Hallmark)*
55
What is the treatment for Croup?
- POC
- Oxygen and humidified air
- Racemic Epinephrine (can rebound in 60-90 minutes) (this decreases mucosal edema and laryngeal spasm)
- Corticosteroids
- Hydration
- Reduce the work of breathing.
56
What is Acute Epiglottitis?
A life threatening edema of the epiglottis and epiglottic folds (supraglottic).
Is misdiagnosed as croup 20% of the time.
57
What are the usual offending organisms that cause Croup?
- Group A beta hemolytic strep
- Strep pneumoniae
- H Flu
58
What are the characteristic findings of Acute Epiglottitis?
- rapid onset
- fever of 101 or greater
- Lethargy
- sore throat
- *Tripod Position
- *Drooling
- *Exhausted facial expression
- *Lateral neck x-ray - thumbprint sign
***Do not examine Pharynx***
59
What is the treatment for Acute Epiglottitis?
- Decrease stress
- Humidified oxygen
- May need intubation
60
Describe Hyperventilation:
- Rapid breathing in which carbon dioxide is rapidly blown off.
- May be anxiety, but must do differential diagnosis because may be pathophysiological reason for the hyperventilation. Always look at ABGs.
61
Manifestations of Hyperventilation:
- Dyspnea
- Tingling lips/extremities
- Chest pain
- jaw pain
- Air hunger
- Diaphoresis
- Panicky
- Carpopedal spasm (claw hands)
- headache
- Confusion
- if anxiety driven = CO2 will be decreased and PO2 will be normal
62
Treatment for Hyperventilation:
- Rule out causes.
- Paper bag to rebreathe CO2.
63
What is a Pleural Effusion?
Excess fluid in the pleural space.
64
What are the Etiologies of a Pleural Effusion?
- Increased subpleural capillary pressure.
- Decreased capillary oncotic pressure.
- Impairment/obstruction of lymphatic flow.
- Inflammatory conditions.
- Most Common:
- CHF
- Pneumonia
- Malignancy
- Pulmonary Embolus
65
Manifestations of Pleural Effusion:
- Dyspnea
- Chest pain
- Tachypnea
- Dullness to percussion
- Diminished auscultation
- can cause mediastinal shift
- Accessory muscle use
66
Treatment for Pleural Effusion:
- Thoracentesis (diagnostic, therapeutic)
- If empyema - must be drained an treated.
67
Describe Pneumonia:
- Infectious process from inflammation of the pulmonary parenchyma in response to invasion of tissues.
- Is the 6th leading cause of death in the U.S.
- Is the leading cause of death in the elderly.
68
What are the Etiologies for Pneumonia?
- Viral
- Bacterial
- Mycoplasma
- Fungi
- Rickettsiae
- Parasites
69
What are some Risk Factors for Pneumonia?
- Bedridden
- Rib fractures
- Underlying cardio-pulmonary
- Smoking
- Diabetes
- Steroids
- Immunosuppressives
70
Manifestations of Pneumonia:
- Dyspnea
- Chest pain
- Chills
- Cyanosis
- Crackles
- Tachycardia
- Cough
- Fever
- Change in sensorium
- Tachypnea
- Pleura Friction Rub
- Signs of respiratory distress.
71
What is the treatment for Pneumonia?
- Oxygen
- Suction
- IV
- Antibiotics - be sure to do cultures first.
- Bronchodilators
- Antipyretics
- Monitor for dysrhythmias (hypoxia/acidosis)
- Intubation
72
What is a Pulmonary Embolus?
- Most common pulmonary complication in hospitalized patients.
- 3rd leading cause of death in the U.S. - 50,000 deaths per year.
- 70-90% of all elderly patients who die in hospital are found at autopsy to have Pulmonary Embolus.
- causes complete or partial obstruction of pulmonary capillary vascular use.
- Massive = > 50% occlusion of larger artery.
-Submassive = < 50% occlusion.
73
What is Virchow’s Triad (risk factors) for PE?
Hypercoagulability:
- malignancies
- Birth control pills
- Dehydration
- Fever
- Sickle Cell crisis
- pregnant
- Sepsis
Vessel Injury:
- Trauma
- IV drug use
- Aging
- DM
- Atherosclerosis
Venous Stasis:
- Immobilization
- Obesity
- Age
- Burns
- Pregnancy
- CHF
- Recent surgery
- Dysrhythmias (A-fib)
- Cardioversion
74
Manifestations of Pulmonary Embolus:
- Tachypnea
- Tachycardia
- Crackles
- Pleuritic chest pain
- Restlessness
- Hypotension
- Cyanosis
- Pleural friction rub
- Hemoptysis
- Confusion
- Right sided heart failure
- Petechiae
75
What are some Laboratory studies related to Pulmonary Embolus?
- Chest X-ray (after 24 hours may see small infiltrates.)
- Increased Sed Rate
- Increased WBC
- ABG’s - decreased PO2
- Increased D-Dimer
- EKG
- Doppler studies
- V-Q scan
- Pulmonary Angiography (*definitive diagnosis)
- CT
- MRI
76
Treatment for Pulmonary Embolus:
- Oxygen
- foley
- Anticoagulants
- Bronchodilators
- Analgesics
- Agents for BP and cardiac output
- Thrombolytic Therapy (TPA, streptokinase, Urokinase)
- surgical placement of vena caval umbrella/ greenfield filter/ Bird’s nest filter)
- Pulmonary Embolectomy
77
What are some important things to know about rib fractures?
- Fractures of first and second ribs requires great force so they may have other injuries.
- 40% mortality from laceration of subclavian vein or artery.
- Lower rib fractures may have abdominal injuries.
78
What are the manifestations of a rib fracture?
Pain
Audible crepitus
Subcutaneous emphysema
Hypo ventilation
Splinting
X-rays – 70% accurate for fracture
79
What is the treatment for a rib fracture?
High Fowlers
Analgesics
Nerve blocks
Cough and deep breathing
Spirometry
80
What are some reasons for possible hospitalization with rib fractures?
Fractures of three or more ribs.
First and second rib fractures.
Sternal fracture
History of COPD
Displaced fracture
Jagged edges
Flail chest
81
A right lower rib fracture can cause what?
Hepatic injury
82
A left lower rib fracture can cause what?
Splenic injury
83
What is flail chest?
- Two or more adjacent Ribs fractured into two or more locations.
- Free floating segment.
- Paradoxical movement: section drawn inward on inspiration and outward on exhalation.
- Alveolar tissue is compressed causing physiologic shunting and Venus mixing with a resultant decrease in PO2.
84
Manifestations of flail chest:
Paradoxical chest wall movement
Pallor
Confusion
Hypotension
Decreased or absent breast sounds
Hyper/hypoventilation
Cyanosis
Ecchymosis
Diaphoresis
Palpitation of crepitus or fracture
85
What is the treatment for flail chest?
- Oxygen
- Stabilize the chest wall (recommended on injured side in semi Fowlers position)
- Limit intake
- Intubation/ventilation
- Analgesics
- Internal fixation
86
What is a pneumothorax?
- Loss of negative intrapleural pressure which collapses the lung and creates a decreased area of adequate V/Q relationship and hypoxemia.
- Can be fatal
- Can be trauma related or spontaneous.
87
What are the manifestations of a pneumothorax?
- Sudden chest pain
- Dyspnea
- Distended neck veins
- Signs of shock
- Referred pain to shoulder
- Cyanosis
- Hypotension
- Hammon’s crunch (air in mediastinum; “crunch” sound every time heart beats)
88
What is the treatment for a pneumothorax?
Chest tube
Oxygen
Treat for shock
89
What is a tension pneumothorax?
- Allows air to enter pleural space on inspiration but cannot exit on expiration.
- Shifts mediastinum with resulting compression.
90
What are the manifestations of a tension pneumothorax?
- Sudden chest pain
- Dyspnea
- Distended neck veins
- Tracheal deviation (to uninjured side)
- Referred pain
- Cyanosis
- Hypertension
- Signs of shock
91
What is the treatment for a tension pneumothorax?
- Needle thoracostomy (use flutter valve if delay in chest tube will occur)
- 14 to 16 gauge in the second intercostal space midclavicular line above rib.
- Chest tube (fifth intercostal mid axillary line on injured side)
- Oxygen
- IV fluids
- Treat for shock
92
What is a hemothorax?
An accumulation of blood in the pleural space.
93
What are the 3 types of hemothorax?
Minimal - up to 350 mL
Moderate – 350 mL to 1500 mL
Massive - > 1500 mL
94
What are the manifestations of a hemothorax?
Dyspnea
Dullness on injured side
Pain
Decreased breast sounds
Shock
Possible mediastinal shift
95
What is the treatment for a hemothorax?
Oxygen
Chest tube
Autotransfusion
Thoracotomy
Analgesics
POC
96
What is an open pneumothorax?
- Life-threatening condition.
- Penetration into chest wall (2/3 the size of the tracheal opening)
- Produces a sucking sound
- Immediate occlusive dressing taped on three sides.
- Watch for development of tension pneumothorax.
- Remove dressing if tension pneumothorax occurs.
97
What is a pulmonary contusion?
- Bruising of lung.
- Blood extravasates into the lung parenchyma causing alveolar and interstitial edema which causes tissue anoxia. These changes increase pulmonary vascular resistance and decrease the pulmonary blood flow.
- May develop into ARDS.
- Mortality = 40%.
98
What is the manifestations of pulmonary contusion?
Chest pain
Chest wall contusion
Dyspnea
Cough
Hemoptysis
Increasing tachypnea
Tachycardia
99
What is the treatment for pulmonary contusion?
Position injured set up
Oxygen
Humidified breathing treatments
Restrict fluids unless signs of shock
Analgesics
Diuretics
Corticosteroids
100
What are some reasons to consider intubation with a pulmonary contusion?
- Severe hypoxia
- Greater than 28% of lung affected
- Signs of shock
- Fracture of eight or more ribs
- Elderly
- Underlying pulmonary disease
101
What are the manifestations of an esophageal disruption?
- Cough
- Chest pain
- Pseudo mediastinum
- Dyspnea
- Dysphasia
- Hematemesis
- Choking
- Epigastric pain
- Pulmonary contusion
- Respiratory distress
- Neck pain
- Hoarseness
- Subcutaneous/mediastinal emphysema
102
What is the treatment for an esophageal disruption?
Oxygen
IV
Chest tube
Esophagogram/Esphagoscopy
Surgery
103
How can a ruptured bronchus/trachea occur?
From compressive shearing forces of blunt trauma
104
What are the manifestations of a ruptured bronchus/trachea?
- Respiratory distress
- History of violent trauma
- Intercostal retractions
- Fracture of first five ribs
- Cough
- Hemoptysis
- Signs of pneumothorax
- Airway obstruction
- Noisy breathing
- Hammon’s crunch
- Mediastinal/subcutaneous emphysema
- Persistent air leak after chest tube
105
What is the treatment for a ruptured bronchus/trachea?
- Chest tube
- Intubation
- Tracheobronchoscopy
- Surgery
106
What are some special patient populations with regard to respiratory emergencies?
Pediatrics
Geriatrics
107
What is special about pediatrics with regard to respiratory emergencies?
- Infants or obligate nose breathers.
- Children are dependent on diaphragm for adequate chest expansion.
- Remember the signs of distress
1) grunting
2) head bobbing
3) nasal flaring
- Airways are very small - it doesn’t take much to obstruct.
- Airway resistance is 15 times greater than the adult.
- Thin chest walls and cartilaginous ribs.
- Greater body surface area and increased respiratory rate leads to dehydration easily.
108
What is special about geriatrics with regard to respiratory emergencies?
- Decreased:
1) Vital capacity
2) Muscle strength
3) Diffusion capacity
4) Elastic recoil
- Increased:
1) Work of breathing.
2) V-P inequality.
- Have increased infections.
- Dyspnea may be only sign of MI.
- Aspiration mortality high.
- 50% mortality with two rib fractures.
- Decreased cough reflex.
- Pneumonia leading infectious disease.
