Flashcards in Respiratory Emergencies Deck (79):
Abnormally low arterial oxygen tension
What causes hypoxemia?
Hypoventilation-causes increased PaCO2
Right to left shunt
Low inspired air
What is a hallmark of right to left shunt?
failure to increase oxygen levels with supplemental oxygen
Where is stridor hear? What can cause this?
upper airway, inspiratory
FB, croup, epiglottis, anaphylaxis
Where is wheezing heard? What can cause this?
lower airway, expiratory
Asthma, COPD, FB, cardiogenic pulmonary edema
Where are rales heard? What causes this?
sounds like velcro being pulled apart
Where is rhonchi heard? What causes this?
What are the symptoms of hypoxia? (early and late)
is late to BED
When are head bobbing and see saw breathing seen?
in respiratory distress or failure
see saw- using abd muscles for breathing
obstruction of bronchioles
decreased gas exchange, increased exudate
What is the pna triad?
fever, dyspnea, cough
Name the pathogen based pna sputum:
-red currant jelly..
-foul smelling or bad tasting
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
Risk factors for aspiration pna?
poor cough, poor gag reflex, impaired swallowing, GI dysmotility, alcoholism, CNS depression
MCC of pna is S. Pneumoniae, what are the typical presenting sxs?
sudden onset fever, rigors, productive cough, dyspnea
Klebsiella pna is common in?
alcoholics, NH pts
Work up for pna?
Lactic acid (if high think sepsis)
Therapy for pna may include?
cough suppressant with expectorant
Abx for HCAP
Cefepime or Ceftazidime or Piperacillin-tazobactam
+Ciprofloxacin or Levofloxacin
What is CURB 65 used for? What is included in this?
pna mortality predictor
Uremia (BUM >20)
RR >30 breaths per minute
Blood pressure <90 or SBP <60
Age over 65 yrs
High altitude is a....
oxygen concentration remains constant
most pronounced during sleep
How do our bodies acclimate to high altitude?
hypoxic ventilatory response:
-carotid body senses decrease in arterial o2
-stimulates medulla to increased ventilation rate
What does Actezolamide cause?
What happens to blood at high altitude? fluid?
erythropoietin increases in plasma
peripheral venoconstriciton increases central blood volume, ADH & aldosterone suppressed >diuresis
What kind of breathing is common above 9000 ft?
Sxs of acute mountain sickness?
HA- bifrontal worse with bending over or valsalva
PE findings in patient with acute mountain sickness?
+/- postural hypotension
Pathophys of acute mountain sickness?
due to hypobaric hypoxia
cerebral blood increases > brain enlarges > vasogenic edema develops
Tx for acute mountain sickness?
stop ascending! Go back down to lower elevation
high dose: ASA or Tylenol or Motrin (600-800mg)
Dexamethasone 4mg Q6hrs
How can you prevent acute mountain sickness?
avoid overexertion, alcohol or respiratory depressants
eat high carb meals (yummm)
Acetazolamide 24hrs before ascent
Presentation of high altitude cerebral edema?
Acute mountain sickness (AMS) with neuro sxs
-CN palsy 3, 6
Tx for high altitude cerebral edema?
Loop diuretics: Furosemide. Bumetanide
What is the most lethal of the high altitude illnesses?
high altitude pulmonary edema
Sxs of high altitude pulmonary edema?
dry cough, later progresses to productive
decreased exercise performance
what causes high altitude pulmonary edema?
due to high pulmonary microvascular pressures and development of pulmonary HTN
Tx for high altitude pulmonary edema?
O2 > may take 72 hrs to resolve
Nifedipine 20 mg Q8hrs
s/s of CHF
hypoxemia, HTN, tachycardia, dyspnea, weight gain, rales
Sxs left sided HF?
dyspnea, fatigue, cough, PND, orthopnea
peripheral edema, JVD, RUQ pain
CHF work up should include....
Chemistries- electrolytes, renal fun.
CXR -b lines, cardiomegaly, etc.
BNP over....suggests HF
Tx for CHF?
o2 and ventilation
Nitro-reduces preload and BP
Diuretic- furosemide. Bumetanide
What drugs should you AVOID in pts presenting with CHF?
CCB > cause pulmonary edema and cardiogenic shock
NSAIDS > inhibit effects of diuretics
What's virchow's triad?
Risk for PE/DVT
-Vessel wall inflammation
s/s of PE
dyspnea, pleuritic CP, syncope, LE pain/swelling, confusion/anxiety, hypoxemia
TRIAD: pleuritic CP, SOB, hemoptysis
What can we use for risk assessment of PE/DVT?
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
Interpretation of wells score?
0-1 low risk 3.6% chance
2-6 moderate 20.5% chance
>6 high 66.7% chance
What can you use to r/o PE?
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 estrogen use
No unilateral leg swelling
if all YES, risk is less that 2%
CXR for PE?
Hampton's hump: triangular pleural based infiltrate
What tests can you check for PE?
CT** test of choice
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
May have elevated: pro-BNP, Trop
What does D-dimer measure?
fibrin degradation products, lots of things elevate this!
EKG in PE?
MC finding: sinus tachycardia
Tx for PE?
Heparin if/when in the hospital
then one of the following:
- Rivaroxaban (Xarelto)
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
Thrombolytic agents for PE? other options?
Alteplase (Activase) tPA-only one with FDA approval
Mechanical: embolectomy, catheter directed thrombolysis
What is asthma? Pathophys triad?
chronic (but reversible) inflammatory disorder
Obstruction to airflow
Clinical triad for asthma?
dyspnea, wheezing, cough
chronic irreversible disorder
includes: chronic bronchitis and emphysema
S/S of COPD?
cough- usually worse in the AM
What can we use to assess COPD?
blood tests- not usually indicated
Cornerstone of obstructive airway therapy?
corticosteroids- for exacerbations
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
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)
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
MOA of corticosteroids?
reduce inflammation and upregulate B receptors
When is magnesium sulfate used?
For severe asthma exacerbations-haven't responded to multiple txs
inhibits smooth muscle action potential leading to bronchodilation
What are some other options for asthma exacerbations?
Heliox- reserved for severe rxns (peds)
Peak age occurrence for FB aspiration?
btwn 1-3 yrs old
second peak at 85 yrs of age
Presentation of FB aspiration?
depends on size and location of FB
Cough > acute airway obstruction
Stridor > laryngotracheal FB
wheezing > bronchial FB
universal chocking sign
What should be considered in all children with unilateral wheezing and persistent symptoms that do not respond to bronchodilators?
Dx of FB aspiration?
CXR- often no helpful, hyperexpansion of unilateral lung field
Laryngoscopy and/ror bronchoscopy
Common locations for FB?
MC- thoracic inlet, at level of clavicles on CXR
If coin appears turned to the side on AP CXR it is likely in the...
What should you do for an conscious patient who you suspect was chocking?
NO blind finger sweep
What's the difference btwn stridor and wheezing?
Stridor: Inspiratory sound,
Wheezing: Expiratory sound, lower airway
What is the clinical significance of head bobbing and see saw breathing?
both are signs of impending respiratory failure
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?
What is the treatment of choice for high altitude pulmonary edema?
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)