Respiratory Emergencies Flashcards
(82 cards)
1
Q
Dyspnea Definition
A
Subjective feeling of difficult, labored, or uncomfortable breathing
2
Q
Tachypnea Definition
A
Rapid breathing
Normal varies by age
3
Q
Bradypnea Definition
A
Slow breathing
4
Q
Orthopnea Definition
A
Dyspnea in recumbent position
MC in CHF
5
Q
Paroxysmal nocturnal dyspnea definition
A
Dyspnea that awakens pt from sleep
6
Q
Hypoxia Definition
A
Insufficient delivery of O2 to tissues.
SaO2 < 94% on Room Air
7
Q
Hypoxemia (Blood Gas)
A
Abnormally low arterial O2 tension
PaO2 < 60mmHg
8
Q
Causes of Hypoxemia
A
Hypoventilation-increased PaCo2
Right-2-Left shunt: hallmark = failure to increase O2 levels with supplemental O2
V:Q mismatch
Diffusion
Low inspired O2 (high altitudes)
9
Q
Stridor
A
Upper Airway
Inspiratory
Foreign body, croup, epiglottis
Anaphylaxis
10
Q
Wheezing
A
Lower Airway
Expiratory
Asthma, COPD, foreign body, cariogenic pulmonary edema
11
Q
Rales
A
Lower airway
Sounds like velcro pulled apart
CHF
12
Q
Ronchi/crackles
A
Lower airway
PNA
13
Q
Symptoms of Hypoxia
A
Early:
Restlessness
Anxiety
Tachycardia/pnea
Late:
Bradycardia
Extreme Restlessness
Dyspnea
Peds: Feeding difficulty Inspiratory stridor Nares Flare Expiratory Grunt Sternal retracting
14
Q
Respiratory distress or failure
A
Inadequate O2 and/or vent
Signs: Tachypnea/bradypnea, retractions, nasal false, head bobbing (up for inhale, down for exhale), pre-arrest, AMS, See-saw breathing (abd muscles) hypoxia
Grunting = late
15
Q
PNA
A
Infection of alveoli
Triad: FEVER, DYSPNEA, COUGH
Sputum: Rust = Step PNA (MC) Green = Pseudo, Haemophilus Red currant: Klebsiella Foul-smelling or bad-test: anaerobes
Signs/symp:
brady/hypoNa: legionella
Bulls myringitis: myco PNA
16
Q
CAP vs HAP vs VAP
A
CAP: pt no hospitalized/resident of LTC x 14 days prior
HAP (nosocomial): > 48hr post-admit
VAP: PNA > 48 hr post-intubate
17
Q
Healthcare-associated
A
pt hospitalized > 2d last 90d NH resident IV ABX HD Chronic Wounds Chemo Immunocomprosmised
18
Q
Aspiration PNA
A
Inhalation of oropharyngeal secretion
Risk increased: poor cough (muscle weakness) poor gag reflex Impaired swallow GI dysmotility ETOH CNS depression
19
Q
Streptococcus PNA
A
MCC PNA
symptoms: sudden fever, rigors, productive cough, dyspnea
Risks: elderly, <2y.o
minorities
Day care
Underlying medical conditions
Lobar infiltrate
para-PNA pleural effusion (around infiltrate)
20
Q
Lobar Infiltrates on CXR
A
Heart edge = RML
Upper, no touch: RUL
Lower, Heart border intact: RLL
If on L and hits heart: LUL (lingular)
21
Q
Staph Aureus PNA
A
Common following viral
CXR shows extensive infiltrates (Cavitations)
22
Q
Klebsiella PNA population
A
Common in ETOH, NH its
23
Q
PNA diagnostic testing
A
CXR, CT (CT tech better) CBC Chems ABG Blood cultures (req'd if you admit) Lactic Acid (measures if tissues getting enough NTR/O2; also treatment measure)
24
Q
PNA Therapy
A
IVF (NS/LR) Antipyretics (HR incr 10 /1degree over normal) O2 Bronchodilator Abx Cough Suppressant w/ expectorant Steroids
25
HCAP Abx
```
Cefepime
Ceftazidime
Piperacillin-Tazobactam
Ciprofloxacin
Levofloaxin
Vancomycin
```
26
CURB 65
```
Mortality Predictor
Confusion
Uremia (BUN>20)
Resp Rate > 30 br/min
BP < 90mmHg sys/60mmHg dia
Age > 65
```
0-1 OP
2 admit
3-5 ICU
27
High Altitude Illness
Partial Pressure of O2 decr as barometric pressure changes
elevates >5000ft (MC 8-14K)
Most pronounced during sleep
Most critical: sleeping altitude and rate of ascent
28
Altitude Acclimation (ventilation response)
1. Carotid body senses decr in art O2
2. Stimulates medulla to incr. vent rate (resp alka)
3. Response lessened by rest depressants, chronic hypoxia
4. Acetazolamide causes bicarb diuresis
29
Altitude Acclimation (blood)
Erythropoietin increased in plasma
Increases RBC mass
Starts as early as 2 hours after ascent
30
Altitude Acclimation (fluid)
Peripheral venoconstriction increases central blood volume
| ADH and aldosterone suppressed causes diuresis
31
Altitude Acclimatization (CVD)
HR incr. to compensate for decr stroke volume
Max exercise HR decr
Pull vessels constrict
Cerebral blood flow increases
32
Altitude Acclimatization (sleep)
Cheyne-Stokes breathing common > 9000 ft
33
Acute Mountain Sicknesss
Si/sx: lightheaded, dizzy, H/a (bifrontal, incr bending over/valsalva), breathlessness w/ activity, anorexia, Nausea, weakness, irritability
Findings: postural Hypotension, rales up to 20% retinal hemorrhages, FLUID RETENTION (decr urination)
34
Acute mountain Sickness Patho
Hypoaric hypoxia
1. Cerebral blood increases
2. Brain enlarges
3. Vasogenic Edema develops
35
Acute Mountain Sickness Treatment
```
Halt further ascent until symptoms resolve
500-1000m descent rapidly effective
O2 0.5-1L/min
Acetazolamide (has sulfa)
ASA, tylenol, motrin
Dexamethasone
```
36
Acute Mountain Sickness Prevention
Gradual Ascent
Avoid overexertion, ETOH, Respiratory depressant
Eat High CHO meal
Start Acetazolamide 24 hr before ascent (stop 2 days at altitude, resume if symptoms reoccur)
Dexamethasone
37
High Altitude Cerebral Edema
AMS w/ neuro symptoms
-ataxia, stupor, coma, CN 3,6 palsy
Trx: O2, descent/evacuate, dexamethasone, loop diuretics
38
High Altitude Pulmonary Edema (Si/sx)
Most lethal of high altitude illnesses
Si/sx: dry cough prog into productive, decr exercise performance incr recovery time, rales (incr post-ex), incr dyspnea, Coma, death
39
High Altitude Pulm Edema trx and background
Due to high pulm microvascular pressures development of pulm HTN
Trx: recognition, TOC: IMMEDIATE DESCENT, O2 (72 hr), Nifedipine
40
CHF (MC's)
MC reason for admit in Medicare pts
MCC: LV dysfxn (Aortic Stenosis, HTN, A fib, CAD)
41
CHF (Si/sx)
hypoxemia, HTN, tachycardia, dyspnea, wt gain, rales
42
Right vs Lef sided
Left: dyspnea, fatigue, cough, PND, orthopnea
| Right (Swelling)): Peripheral Edema, JVD, RUQ pain
43
CHF Testing
```
CBC (anemia)
Chems (lytes, renal fxn)
Cardiac Enzymes
Pro-BNP (released by ventricular myocardium 2/2 stretching; >200)
EKG: LV hypertrophy, dysrhythmias, STEMI
CXR: low sensitive, dilated upper lobe vessels, cardiomegaly, interstitial edema, enlarged pulm artery, pleural effusions, kerley lines
U/s: lung: B lines (comet tails)
Echo: LV/valve fxn, tamponade, VSD
```
44
CHF Trx
Adequate O2/vent (non-invasive vs invasive)
Nitro (decr preload, bp)
Morphine sulfate (decr preload, anxioloysis)
Diuretic (furosemide = MC; 90 min, causes ventilation, diuresis)
Dobutamine (+ inotropic effect w/ mild chornotropic; in addition to Nitro)
CCB: may cause pulm edema, card shock
NSAIDS: inhibit effect of diuretics
Anti-arrhythmic's: pro-arrhythmic effects
45
Pulm Embolism (PE) background
3rd lead COD hospital
MCC nonsurgical maternal death peripartum
Occurs when prox venous thrombosis breaks off and travels to lung
-MC pelvic or deep LE veins (any except intracranial)
Virchow's triad
46
What is virchow's triad
Venous stasis
Vessel wall inflammation
Hypercoagulability
47
PE Risk Factors
```
Malignancy
Obesity
Immobilization
Surgery
Trauma
```
```
CHF
Age > 40
Mobility (lack)
Estrogen excess
Long bone fx
Smoke
```
48
PE Si/sx
Dyspnea, pleuritic chest pain (50%), syncope, LE pain/swell, confusion, anxiety, hyperemia
measure tibial tuberosity, <2cm difference between calves
TRIAD: PLEURISY, SOB, HEMOPTYSIS
49
PE Risk (wells)
```
Wells score
3=suspected
3=alt dx less likely
1.5= tachycardia
1.5 = immobile, sx (4 wks)
1=hemoptysis
1=malignant
```
```
0-1 = low
2-6 = mod
>6 = high
```
50
PE Risk (geneva)
```
Age >65
Active malignant
u/l LLE pain
prev DVT/PE
Hemoptysis
Recent sx/frx
tender LE veins or u/l LE edema
HR 75-94 (x2>94)
```
Low = 2
High >2
51
PE risk (PERC)
```
PE r/o
<50
PO >94%
HR < 100
o prior venous thromboembolism
no recent sx/trauma 4 weeks
no hemopotyis
no estrogen use
no u/l swelling
```
if all yes, risk < 2%
52
PE testing
CXR: normal 1/3
-hamptoms hump, westermarks, felischner sign
V/Q scan
CT scan (Test of CHOICE)
-central clots, may miss small peripheral; req iodine
Echo: limited, R ventricular dyxfxn
Venous compression u/s
```
Blood: ABG - widened A-a gradient (alveolus vs artery)
D Dimer: fibrin degradation
Pro-BPN
Troponin
EKG: Sinus tacky (t-wave), S1Q3T3
```
53
PE trx
Heparin, coumadin, lovenox, rivaroxaban, vena caval filter (contra to anticoag)
54
Thrombolytic trx (indicate/contra)
Ind: massive PE, hemo unstable, massive ileofemoral DVT, large DVT w/ vascular compromise
Contra: major bleed last 6 mos, IC/spinal sx or trauma (2 mos), sx last 10d, peri/endocarditis, uncontrolled HTN (200/110), pregnancy, suspected aneurysm
55
Thrombolytic trx (agents)
Streptokinase
Urokinase
Alteplase
56
Thrombolytic trx (mech)
Embolectomy (massive PE w/ contra to fibrinolysis or unstable after)
Catheter directed thrombolyisis (alteplase + heparin)
57
Asthma background
Chronic reversible inflammatory d/o
58
Asthma Patho triad
Airway inflammation
obstruction to airflow
bronchial hyper responsiveness
59
Asthma Clinical Triad
Dyspnea
Wheeze
Cough
60
COPD
Chronic Irreversible d/o
Bronchitis: chronic productive cough x 3 dos in 2 yrs (clinical dx)
Emphysema: destruction of bronchioles and alveoli, pathologic d/x
61
COPD Etiology
```
Tobacco use (MC)
Occupational exposures
Environment exposures (pollution)
Alpha 1-antitrypsin deficit
IVDA
```
62
COPD si/sx
```
cough (worse in AM)
SOB
wheeze
tachypnea
cyanosis
```
63
COPD Assessment
FEV1 (pt dependent)
can also be used to monitor therapy response
Pulse ox
CXR (abnormal only 1/3)
64
COPD trx
Goals: reverse obstruction, provide adequate O2, relieve inflammation
65
Beta Agonist
Cornerstone of COPD therapy
B1: incr rate/force cardiac, SI motility
B2: bronchodilation, vasodilator, uterine relax, tremor (small airways mostly)
Ex: albuterol
Delivery: MDI/Nebulizer (Spacer w/ MDI); intermittent vs continuous, Inhaled vs IV/SQ (longer into lungs!)
66
Epinepherine
Bronchodilator (not B selective)
Nebulizer, SQ, IM
No benefit over albuterol
Only give IV in code
67
Ipratropium Bromide
blocks cholinergic stimulation of airway smooth muscle
primarily on large central airways
give w/ beta agonists
68
Corticosteroids
another cornerstone of therapy
decr inflammation and up regulate B receptors
high dose not recommended
-one
69
Mg SUlfate
Severe exacerbations
| inhibits SM action potential leading to bronchodilation
70
Other COPD meds
Heliox (80% helium w/ O2) for severe, not for those needing increased O2
Theophylline (no longer)
Ketamine (conscious sedation); doesn't affect VS but opens airway
71
BiPAP indicate/contra
indicated: cooperative, dyspnea, tachypnea, increased work to breath, hypoxemia
Contra: emergent intubate, cardiac/resp arrest, inability to protect airway/clear secretions, decreased LOC, facial trauma/deformity, recent esophageal surgery
72
Bipap deliver
Facial, nasal, helmet, vent
73
What is BiPap
Bilevel + Airway Pressure
IPAP = inspiratory; EPAP = expiatory
IPAP - EPAP = pressure support (PEEP)
74
Risk factors for death in COPD
```
Prev severe exacerbation (intubate/ICU)
>2 hospital
>3 ED
hosp/ED last month
>2 MDIs/month
Diff perecieng symptom severity
low SES
illicit drug use
Psych illness
```
75
COPD symptom progression
```
Chest tightness
cough
wheeze
prolonged expire
accessory muscle use
alteration in mental status
```
76
Foreign Body Aspriation
Potentially life-threatening event
peak age: 1-3; >85
4th COD accidentally @ home
RF: childhood development, too large food, fed by older siblings, small parts
Lethal objects: PB, nuts, marbles, grapes, balloons, beads, hotdog
77
FB aspirate adult risks
```
Risk: altered LOC
impaired swallow
Stroke dysphagia
Alzheimer dementia
Parkinson's
```
78
FB presentation
```
Depends on size and location of FB
Cough (acute)
stridor = laryngotracheal
wheeze = bronchial
SOB, cough, wheeze
```
universal choking sign
79
what if no hx?
high index suspicion
dx considered in all kids w/ u/l (esp R) wheeze + persistent symptoms that don't respond to bronchodilators
CXR may be normal in 50%
80
FB Dx
CXR (radio-opaque), U/L hyper inflate
CT
Laryngoscopy/bronchoscopy
81
Common Locatiosn for FB
MC: thoracic inlet (~clavicles); skeletal to smooth muscle
Cricopharyngeus muscle
Mid esophagus (aortic arch/carina)
Distal esophagus (lower essophageal sphincter)
82
FB trx
conscious: heimlich; ask if you are choking and if i can help
Alone: self-hemilich
infant/child: between scapula on knee, CPR
Unconscious: CPR, no blind finger sweep
