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Flashcards in Respiratory Emergencies Deck (79):
1

Define hypoxemia

Abnormally low arterial oxygen tension

PaO2 <60mmHg

2

What causes hypoxemia?

Hypoventilation-causes increased PaCO2

Right to left shunt

Ventilation-Perfusion mismatch

Diffusion

Low inspired air

3

What is a hallmark of right to left shunt?

failure to increase oxygen levels with supplemental oxygen

4

Where is stridor hear? What can cause this?

upper airway, inspiratory

FB, croup, epiglottis, anaphylaxis

5

Where is wheezing heard? What can cause this?

lower airway, expiratory

Asthma, COPD, FB, cardiogenic pulmonary edema

6

Where are rales heard? What causes this?

lower airway

sounds like velcro being pulled apart

CHF

7

Where is rhonchi heard? What causes this?

lower airway

pneumonia

8

What are the symptoms of hypoxia? (early and late)

Early RAT:
-restlessness
-anxiety
-tachycardia/tachypnea

is late to BED
-bradycardia
-extreme restlessness
-dyspnea

9

When are head bobbing and see saw breathing seen?

in respiratory distress or failure

see saw- using abd muscles for breathing

10

Describe pna

obstruction of bronchioles

decreased gas exchange, increased exudate

11

What is the pna triad?

fever, dyspnea, cough

12

Name the pathogen based pna sputum:

-rust colored...
-green colored..
-red currant jelly..
-foul smelling or bad tasting

s. pneumoniae

pseudomonas, Heamophilus

klebsiella

anaerobes

13

Pt with sxs suggestive of pna...the following additional symptoms makes you concerned that it is do to which pathogens?

1. bradycardia and hyponatremia

2. Bullous myringitis

Legionella

mycoplasma pneumoniae

14

Risk factors for aspiration pna?

poor cough, poor gag reflex, impaired swallowing, GI dysmotility, alcoholism, CNS depression

15

MCC of pna is S. Pneumoniae, what are the typical presenting sxs?

sudden onset fever, rigors, productive cough, dyspnea

16

Klebsiella pna is common in?

alcoholics, NH pts

17

Work up for pna?

CXR, CT
CBC
Chemistries
ABG
Blood cultures
Lactic acid (if high think sepsis)

18

Therapy for pna may include?

IV fluids
antipyretics
oxygen
bronchodilator
abx
cough suppressant with expectorant
steroids

19

Abx for HCAP

Cefepime or Ceftazidime or Piperacillin-tazobactam

+Ciprofloxacin or Levofloxacin

+Vancomycin

20

What is CURB 65 used for? What is included in this?

pna mortality predictor

Confusion
Uremia (BUM >20)
RR >30 breaths per minute
Blood pressure <90 or SBP <60
Age over 65 yrs

0-1 outpt
2-admit
3-5 ICU

21

High altitude is a....

hypoxic environment

oxygen concentration remains constant

most pronounced during sleep

22

How do our bodies acclimate to high altitude?

hypoxic ventilatory response:
-carotid body senses decrease in arterial o2

-stimulates medulla to increased ventilation rate

-HR increases

23

What does Actezolamide cause?

bicarbonate diuresis

24

What happens to blood at high altitude? fluid?

erythropoietin increases in plasma

peripheral venoconstriciton increases central blood volume, ADH & aldosterone suppressed >diuresis

25

What kind of breathing is common above 9000 ft?

Cheyne-Stokes breathing

26

Sxs of acute mountain sickness?

lightheadedness/dizziness

HA- bifrontal worse with bending over or valsalva

anorexia, nausea

weakness, irritability

27

PE findings in patient with acute mountain sickness?

+/- postural hypotension

localized rales

retinal hemorrhages

fluid retention**

28

Pathophys of acute mountain sickness?

due to hypobaric hypoxia

cerebral blood increases > brain enlarges > vasogenic edema develops

29

Tx for acute mountain sickness?

stop ascending! Go back down to lower elevation

Oxygen

Acetazolamide

high dose: ASA or Tylenol or Motrin (600-800mg)

Dexamethasone 4mg Q6hrs

30

How can you prevent acute mountain sickness?

ascend gradually

avoid overexertion, alcohol or respiratory depressants

eat high carb meals (yummm)

Acetazolamide 24hrs before ascent

Dexamethasone

31

Presentation of high altitude cerebral edema?

Acute mountain sickness (AMS) with neuro sxs
-Ataxia
-Stupor
-Coma
-CN palsy 3, 6

32

Tx for high altitude cerebral edema?

O2

descent/evacuation

Dexamethasone

Loop diuretics: Furosemide. Bumetanide

33

What is the most lethal of the high altitude illnesses?

high altitude pulmonary edema

34

Sxs of high altitude pulmonary edema?

dry cough, later progresses to productive

decreased exercise performance

rales, dyspnea

coma, death

35

what causes high altitude pulmonary edema?

due to high pulmonary microvascular pressures and development of pulmonary HTN

36

Tx for high altitude pulmonary edema?

immediate descent

O2 > may take 72 hrs to resolve

Nifedipine 20 mg Q8hrs

37

s/s of CHF

hypoxemia, HTN, tachycardia, dyspnea, weight gain, rales

38

Sxs left sided HF?

right?

dyspnea, fatigue, cough, PND, orthopnea

peripheral edema, JVD, RUQ pain

39

CHF work up should include....

CBC- anemia
Chemistries- electrolytes, renal fun.
Cardiac enzymes
Pro-BMP
EKG
CXR -b lines, cardiomegaly, etc.
Echo

40

BNP over....suggests HF

200

41

Tx for CHF?

o2 and ventilation

Nitro-reduces preload and BP

Morphine Sulfate

Diuretic- furosemide. Bumetanide

Dobutamine

42

What drugs should you AVOID in pts presenting with CHF?

CCB > cause pulmonary edema and cardiogenic shock

NSAIDS > inhibit effects of diuretics

anti-arrhythmics

43

What's virchow's triad?

Risk for PE/DVT

-Venous stasis
-Vessel wall inflammation
-hypercoagulability

44

s/s of PE

dyspnea, pleuritic CP, syncope, LE pain/swelling, confusion/anxiety, hypoxemia

TRIAD: pleuritic CP, SOB, hemoptysis

45

What can we use for risk assessment of PE/DVT?

Wells Score:

3 - Suspected DVT
3 – Alternative diagnosis less likely than PE*
1.5 – Heart rate >100bpm
1.5 – Immobilization or surgery within previous 4 weeks
1.5 – Previous DVT/PE
1 – Hemoptysis
1 – Malignancy

46

Interpretation of wells score?

0-1 low risk 3.6% chance

2-6 moderate 20.5% chance

>6 high 66.7% chance

47

What can you use to r/o PE?

PERC criteria:

Age <50 years old
Pulse oximetry >94% on room air
Heart rate <100 bpm
No prior venous thromboembolism
No recent surgery or trauma within prior 4 weeks
Requiring hospitalization, intubation, epidural anesthesia
No hemoptysis
No estrogen use
No unilateral leg swelling

if all YES, risk is less that 2%

48

CXR for PE?

1/3 normal

+/-
Hampton's hump: triangular pleural based infiltrate

Westermark's sign*

Feischner sign

49

What tests can you check for PE?

CT** test of choice

CXR

V/Q scan- normal perfusion can exclude PE

Echo- not really used

venous compression US- for LE

ABGs- 75% room air hypoxia, 65% widened A-a gradient

D-dimer

May have elevated: pro-BNP, Trop

50

What does D-dimer measure?

fibrin degradation products, lots of things elevate this!

51

EKG in PE?

MC finding: sinus tachycardia

specific: S1Q3T3

52

Tx for PE?

Heparin if/when in the hospital

then one of the following:
-Coumadin
-Lovenox
- Rivaroxaban (Xarelto)

53

Indications for thrombolytic tx for PE? contraindications?

massive PE, hemodynamically unstable

massive iliofemoral DVT

large DVT with sig. vascular compromise

contraindications: bleeding risks, uncontrolled HTN, pregnancy

54

Thrombolytic agents for PE? other options?

Streptokinase

Urokinase

Alteplase (Activase) tPA-only one with FDA approval

Mechanical: embolectomy, catheter directed thrombolysis

55

What is asthma? Pathophys triad?

chronic (but reversible) inflammatory disorder


Airway inflammation

Obstruction to airflow

Bronchial
hyperesponsiveness

56

Clinical triad for asthma?

dyspnea, wheezing, cough

57

Describe COPD

chronic irreversible disorder

includes: chronic bronchitis and emphysema

58

S/S of COPD?

cough- usually worse in the AM

SOB
wheezing
tachypnea
cyanosis

59

What can we use to assess COPD?

FEV1

pulse ox

CXR

blood tests- not usually indicated

60

Cornerstone of obstructive airway therapy?

beta agonist

corticosteroids- for exacerbations

61

What is the best method for delivery of beta agonist? MDI v. nebulizer? Intermittent v. continuous?

equal efficacy- must use spacer/chamber device with MDI

continuous reserved for severe exacerbations q

62

How is epinephrine used in obstructive airway disease?

Acts as bronchodilator but is NOT beta selective

no benefit over albuterol, Don't give IV epi unless in code (makes heart beat too fast)

63

Ipratropium Bromide MOA? When is this used?

Blocks cholinergic stimulation of airway smooth muscle

Works primarily on large central airways

Should be given in conjunction with beta agonist

64

MOA of corticosteroids?

reduce inflammation and upregulate B receptors

65

When is magnesium sulfate used?

For severe asthma exacerbations-haven't responded to multiple txs

inhibits smooth muscle action potential leading to bronchodilation

66

What are some other options for asthma exacerbations?

Heliox- reserved for severe rxns (peds)

Theophylline

Ketamine

BiPAP

67

Peak age occurrence for FB aspiration?

btwn 1-3 yrs old

second peak at 85 yrs of age

68

Presentation of FB aspiration?

depends on size and location of FB

Cough > acute airway obstruction

Stridor > laryngotracheal FB

wheezing > bronchial FB

universal chocking sign

69

What should be considered in all children with unilateral wheezing and persistent symptoms that do not respond to bronchodilators?

FB aspiration

70

Dx of FB aspiration?

CXR- often no helpful, hyperexpansion of unilateral lung field

CT

Laryngoscopy and/ror bronchoscopy

71

Common locations for FB?

MC- thoracic inlet, at level of clavicles on CXR

mid esophagus

distal esophagus

72

If coin appears turned to the side on AP CXR it is likely in the...

esophagus

73

What should you do for an conscious patient who you suspect was chocking?

CPR

NO blind finger sweep

74

What's the difference btwn stridor and wheezing?

Stridor: Inspiratory sound,
Upper airway

Wheezing: Expiratory sound, lower airway

75

What is the clinical significance of head bobbing and see saw breathing?

both are signs of impending respiratory failure

76

Your patient presents for evaluation of an elevated temperature and productive cough. 134/80, 50, 24, 102.4, 92% RA. Labs are significant for leukocytosis of 16k and sodium of 127. Based on this presentation, what etiologic agent do you suspect?

How do you treat it?

Legionella

Azithromycin

77

What is the treatment of choice for high altitude pulmonary edema?

immediate descent

78

You are evaluating a 56 year old male with history of colon cancer, on chemotherapy, who presents for evaluation of shortness of breath. 90/40, 123, 28, 87% RA, 101.1. How do you proceed?

Standard histories, including HPI

IV, oxygen, monitor

IV fluids (NS or LR)

Chest x-ray

79

What can give you a false positive d-dimer? What can give you a false negative?

cancer, inflammation, infection, aging (>70 yrs), recent surgery, trauma, MI, pregnancy, arterial thrombosis, acute CVA, superficial phlebitis, RA, liver disease

warfarin, symptoms <5 days, small clot burden