Respiratory Emergencies

Question 1

6 Ps of Dyspnea

Answer 1

• Possible FB
• Pulmonary Embolus (PE)
• PNA
• Pump failure
• Pneumo-thorax
• Pulmonary Bronchial Constriction

Question 2

• Dyspnea in recumbent position
• Most commonly seen w/ congestive HF

Answer 2

Orthopnea

Question 3

Dyspnea that awakens pt from sleep

Answer 3

Paroxysmal nocturnal dyspnea

Question 4

• Insufficient delivery of oxygen to tissues
• Most say SaO2 is < ___ on room air

Answer 4

Hypoxia

<94%

Question 5

• Abnormally low arterial oxygen tension
• PaO2

Answer 5

Hypoxemia

<60 mmHg

Question 6

5 causes of hypoxemia

Answer 6

• Hypoventilation (Increased CO2)
• R to L shunt (failure to increase oxygen levels w/ supplemental oxygen)
• V/Q mismatch
• Diffusion
• Low inspired oxygen (high altitudes)

Question 7

• upper airway
• inspiratory
• FB / croup / epiglottitis / anaphylaxis

Answer 7

Stridor

Question 8

• lower airway
• expiratory
• asthma / COPD / FB / cardiogenic pulm edema

Answer 8

Wheezing

Question 9

• Lower airway
• Sounds like velcro being pulled apart
• CHF

Answer 9

Rales

Question 10

• Lower airway
• PNA

Answer 10

Rhonchi

Question 11

• high pitched
• inspiration
• NOT cleared w/ cough
• (discontinuous)

Answer 11

Crackles

Question 12

• Loud, low, course
• Snore
• inspiration or expiration
• MAY clear w/ cough
• (continuous)

Answer 12

Rhonchi

Question 13

• Muscal noise
• inspiration or expiration
• Louder during ____
• (continuous)

Answer 13

Wheezing

Louder during expiration

Question 14

3 early sxs of hypoxia

Answer 14

• Restlessness
• Anxiety
• Tachycardia / Tachypnea

(RAT)

Question 15

Late sxs of Hypoxia

Answer 15

• Bradycardia
• Extreme restlessness
• Dyspnea

BED

Question 16

Sxs of hypoxia in pediatrics

Answer 16

• Feeding difficulty
• Inspiratory stridor
• Nares flare
• Expiratory grunting
• Sternal retractions

(FINES)

Question 17

3 features of PNA

Answer 17

• Increased Exudates
• Decreased Gas exchange
• Obstruction of bronchioles

(EGO)

Question 18

Which organism for PNA?

• Rust colored?
• Green colored?
• Red currant jelly?
• Foul smelling or bad tasting?

Answer 18

• Rust: Strep pneumo
• Green: Pseudomonas / Haemophilus
• Currant: Klebsiella
• Foul: Anaerobes

Question 19

Which organism for PNA?

• Bradycardia , hyponatremia?
• Bullous myringitis?

Answer 19

• Legionella
• Mycoplasma pneumo

Question 20

PNA is the infection of _____.

w/ what 4 things?

Answer 20

alveoli

• bacteria
• viral
• fungal
• yeast

Question 21

Environmental classifications of PNA

• PNA in pt who has NOT been hospitalized or resident of long term care for 14 days prior to presentation
• PNA occuring >48 hrs after admission
• PNA occuring >48 hrs after intubation

Answer 21

• CAP
• HAP (nosocomial)
• VAP

Question 22

Environmental Classification

• PNA in pt hospitalized >2 days within past 90 days
• Nursing Home resident
• IV abx
• Dialysis
• Chronic wound pts
• Pts receiving chemo
• Immunocompromised

Answer 22

Health Care Associated PNA (HCAP)

Question 23

Environmental Classification of PNA

• inhalation of oropharyngeal secretions
• Risk increased w/
  
  • poor cough
  • poor gag reflex
  • Impaired swallowing
  • GI dysmotility
  • Alcoholism
  • CNS depression

Answer 23

Aspiration PNA

Question 24

What is the most common cause of PNA?

Answer 24

Streptococcus pneumoniae

Question 25

Sudden onset of fever, rigors, productive cough, dyspnea

Answer 25

Pneumonia

Question 26

5 risk factors for PNA

Answer 26

* Elderly * Children \<2 yrs * Minorities * Day care * Underlying medical conditions

Question 27

**Which PNA causes:** * lobar infiltrate * 25% w/ para-pneumonic pleural effusion

Answer 27

Streptococcus pneumoniae

Question 28

What is shown here?

Answer 28

Lobar infiltrates from PNA

Question 29

What is shown here?

Answer 29

Lobar infiltrates from PNA

Question 30

Answer 30

Bullous Myringitis

Question 31

Answer 31

Otitis Media

Question 32

**Which organism causing PNA?** * Commonly follows viral infection * CXR usually shows extensive infiltrates

Answer 32

Staphylococcus aureus

Question 33

**Which organism causing PNA?** * Common in alcoholic and Nursing Home pts

Answer 33

Klebsiella

Question 34

* IV fluids * Antipyretics * Oxygen * Bronchodilator * Abx * Cough suppressant w/ expectorant * Steroids

Answer 34

Therapy for PNA

Question 35

Mortality Predictor for PNA

Answer 35

**CURB 65** * Confusion * Uremia (BUN \>20) * RR \>30 * BP \<90/60 * Age: \>65

Question 36

**W/ CURB 65, the patient gets a point for each item** * 0-1 * 2 * 3-5

Answer 36

* **0-1 low :** Outpatient / Home * **2 moderate :** Admission to Hospital * **3-5 high :** ICU

Question 37

* High altitude is a hypoxic environment. * Oxygen concentration _changes or remains constant?_ * Partial pressure of oxygen _____ as barometric pressure changes w/ elevation * Seen at elevations \>\_\_\_\_feet * Most commonly seen at _____ to _____ feet * Most pronounced during \_\_\_\_ * 2 most critical items to consider?

Answer 37

* Remains constant * decreases * 5,000 * 8,000 to 14,000 * sleep * sleeping altitude & rate of ascent

Question 38

**Altitude Acclimatization : Ventilation** _Hypoxic Ventilatory Response:_ * ____ senses decrease in arterial oxygen * Stimulates ____ to increase ventilation rate * Induces respiratory \_\_\_\_\_ * Response is lessened by _____ and \_\_\_\_\_\_ * Acetazolamide causes \_\_\_\_\_\_\_

Answer 38

* Carotid body * medulla * alkalosis * respiratory depressants & chronic hypoxia * bicarbonate diuresis

Question 39

**Altitude Acclimatization : Blood** * _____ increased plasma * Increases red cell \_\_\_\_\_\_ * Begins as early as ___ hours after ascent

Answer 39

* Erythropoietin * mass * 2

Question 40

**Altitude Acclimatization : Fluid** * Peripheral venoconstriction increases \_\_\_\_\_\_ * ADH & aldosterone suppressed leads to what?

Answer 40

* central blood volume * diuresis

Question 41

**Altitude Acclimatization : Cardiovascular** * Heart rate ___ to compensate for ____ stroke volume * Maximum exercise HR increases or decreases? * Pulmonary vessels constrict or dilate? * Cerebral blood flow increases or decreases?

Answer 41

* HR **Increases , decreased** SV * Max exercise **HR decreases** * Pulm vessels **constrict** * Cerebral blood flow **increases**

Question 42

**Altitude Acclimatization : Sleep** * Cheyne-Stokes breathing is common above _____ feet

Answer 42

9,000

Question 43

**Sxs of what?** * lightheaded / dizzy * HA (bi-frontal, increases w/ bending over / valsalva) * breathlessness w/ activity * Anorexia, nausea * Weakness * Irritability

Answer 43

Acute Mountain Sickness

Question 44

**Findings of what?** * Postural hypotension * Localized rales, up to 20% * Retinal hemorrhages * Fluid retention, hallmark finding

Answer 44

Acute Mountain Sickness

Question 45

**Pathophysiology of Acute Mountain Sickness** * Due to ____ hypoxia * Cerebral blood increases --\> brain enlarges --\> ____ edema develops

Answer 45

* hypobaric * vasogenic

Question 46

**Tx for Acute Mtn Sickness** * Halt further ascent until sxs resolve * ____ to _____ m descent is rapidly effective * Oxygen 0.5-1L/min * Which 5 drugs?

Answer 46

* 500 to 1,000 * Acetazolamide * ASA Tylenol * Motrin * Dexamethasone

Question 47

**How do you prevent Acute Mtn Sickness?** * \_\_\_\_ * Avoid what 3 things * Eat meals high in \_\_\_\_\_ * _______ started 24 hours before ascent * Can stop after __ days at altitude / resume after sxs recur * What other drug?

Answer 47

* Gradual ascent * **Avoid:** overexertion, alcohol, respiratory depressants * Carbohydrates * **Acetazolamide** 24 hrs before * 2 * Dexamethasone

Question 48

**High Altitude Cerebral Edema** _AMS w/ neurological sxs_ * "CASA C"

Answer 48

* Coma * AMS * Stupor * Ataxia * CN palsy 3, 6

Question 49

Answer 49

**CN 3 palsy** | (high altitude cerebral edema)

Question 50

Answer 50

**CN 6 Palsy** | (High Altitude Cerebral Edema)