SOB Flashcards

Question

asthma 1st line tx: nebulizers

Answer 1

-Inhaled SABA: Albuterol (Ventolin) -Bronchodilator of the small airways -MDI, MDI with spacer, or nebulizer treatment -MDI is 4-6 puffs q20-40 minutes -Nebulizer: 5mg q20 min x 3 doses -There is no max dose of albuterol inhaler -SE: TACHYCARDIA, Tremors, anxiety, Very high dose ↓ K -Anticholinergics: Ipratropium bromide (Atrovent) -Adjunct for moderate-severe asthma -> never give by itself -Action = Bronchodilation by blocking bronchial smooth muscle -MDI or nebs -Administer WITH the beta agonists (never use solo) -spacer for kids

Answer 2

-Systemic Corticosteroids -Give in all but the mildest cases of acute asthma exacerbation -Main defense against relapse -Delayed action onset: gradual 1-2 hours, peaks 4 hours -Upregulate beta receptors -Side effects: ____________________________ -Oral is just as effective as parenteral -Oral Prednisone 40-60mg daily for 5 days -Children: 1-2mg/kg for 3-5 days -Oral Dexamethasone 16mg daily for 1-2 days -Methylprednisolone 125mg IV or IM (1mg/kg peds) -oral = IM = IV -dont need to know which steroids

Answer 3

-Magnesium sulfate (3rd line): -Smooth muscle relaxer -Indicated in those with impending respiratory failure / severe asthma after 1 hour intensive therapy -Onset of action as early as 2 minutes, lasting 1-2 hours -Single dose of 2g IV in 100NS over 15-30 minutes (25-75mg/kg up to 2 g in children) -Adverse effects: Flushing/hot feeling, bradycardia, muscle weakness, hypotension -Epinephrine SUBQ/IM: Epinephrine 0.1-0.3 mg SC (1:1,000) -Give in cases of allergic reaction usually (not recommended for routine asthma treatment) -Both a bronchodilator and a vasopressor -Heliox -A mix of helium-oxygen (80:20) can be used in severe exacerbations. Helium is less dense than oxygen, it can travel through smaller airways, increasing oxygen or inhaled medical delivery. -Non-invasive ventilation -Requires a cooperative patient, spontaneous breathing -Bronchodilates -> recruits small airways, better beta-agonist facilitation -Decreases WOB, fatigue, oxygenation -> rest for diaphragm -Ketamine -IV bolus and infusion -Sedates the patient and relaxes them, but also increases secretions -recommended induction agent of choice in asthmatic patients requiring intubation

Answer 4

Antibiotics (unless pneumonia) Aggressive hydration Mucolytics Sedation Anti-tussives Decongestants

Answer 5

-The decision to intubate a patient with severe asthma should NOT be taken lightly -Intubation -> laryngospasm, bronchospasm, hypotension, more hyperinflation, peri-intubation arrest -Difficult to manage on ventilator -Permissive hypercapnia (dont know this): -Once intubated, the airway is secure, no need to rush and excessively ventilate -Allow pCO2 to be elevated (eg 60-80mmHg, with SaO288-92%)  acidosis to help oxygen dissociate better. -Increase expiratory phase (↓ RR, ↑ inspiratory flow, ↓ tidal volume, This relaxes the bronchi. )

Answer 6

-Discharge criteria -No (or minimal) wheezing -Feels better! -Ambulates without hypoxia -FEV1 ≥70% predicted or personal best after bronchodilator -Prescription for albuterol MDI +/- steroids -Albuterol MDI 4 puffs q4h PRN ± spacer ± age-appropriate face mask -Prednisone 50mg daily x 5 days (if oral was used) -Consider adding inhaled corticosteroids (ICS) such as fluticasone / budesonide / mometsaone / blecomethasone if the patient is not already on them -Education: -!!Important: teach concept of “controller” vs. “Rescue meds” -!!Important: teach how to use an inhaler -Emphasize need for continual and regular primary care follow up -1 week follow up with PCP -Avoid triggers -asthma action plan

Answer 7

-pericardium -pneumomediastinum -asthma complication -subcutaneous emphysema on the neck can cause

Answer 8

-Clinical signs and symptoms of asthma are…wheezing, chest tightness, cough -History, symptoms, and signs of severe asthma are…recent cold? any meds, hospitialzation -Step-wise treatment for asthma is….albuterol +- ipatropium, steroids, magnesium -The side effects of treatment are… -Diagnostic testing [is not] required for the majority of patients with asthma exacerbations…. -Remember that ASTHMA is COMMON, and it can KILL

Answer 9

-pneumonia -TB -bronchitis- should not have this low of O2 -lung cancer -COPD

Answer 10

-Supplemental oxygen goal 88-92% (100% is too high for COPD) -Start BiPAP to reduce work of breathing -Intubate if BiPAP if contraindicated -Avoid aggressive bag-valve-mask ventilation -Pre-oxygenate only if intubating -Administer !!!bronchodilators, steroids, antibiotics!!! -circulation: -IV access and cardiopulmonary monitoring -Generally tachycardic and hypertensive due to adrenergic drive -Consider auto-PEEP and pneumothorax in hypotensive patients -disability: -depressed LOC -> maybe hypercapnia

Answer 11

-Chronic lung disease: Dyspnea, chronic cough, sputum production -Most common symptom: Exertional dyspnea -Most common cause is SMOKING

Answer 12

-Ask about current attack -Onset -Symptoms (wheezing, productive cough, SOB/DOE, exercise intolerance, sputum change) -Increased use of inhalers, or new requirement of sleeping upright in chair -Ask about baseline function -Exercise tolerance -Home oxygen use -Ask about previous attacks -Frequency of exacerbations -Last exacerbation and normal course of illness (# days admitted, ICU, intubation) -Ask about features that may point to alternative diagnosis -Sudden onset -> PTX / PE? -Fevers -> Pneumonia -CP -> ACS or CHF? -Remember that COPD is a chronic illness with exacerbations, so question WHY TODAY? -Most common: Viral or bacterial infection -Chest problem: Infection (PNA), PE, PTX, Atelectasis, CHF -Meds: Non-compliance, underdosing, b-blockers, sedatives -GI: Uncontrolled GERD -Environmental: Smoking, pollution, weather

Answer 13

Cough Wheezing Chest congestion SOB ↑ Dyspnea ↑ Sputum volume ↑ Sputum purulence Tachycardia Pursed lip breathing Accessory muscle use Hyperresonant chest Barrel chest Wheezing or prolonged expiration

Answer 14

-order these to RO other things -Standard orders -CBC, CMP -VBG -CXR -!!!!ECG – tachycardia, MAT, cardiac mimics (STEMI) -tachy, irregular, p-waves are diff - multifocal atrial tachy -Additional orders if applicable (exclude alternate diagnosis) -Troponin -BNP -D-Dimer ± CT angiogram chest -Viral panel -Sputum culture -POCUS

Answer 15

CHF PE PTX Lung cancer PNA Ischemic heart disease Brain natriuretic protein can be significantly elevated in cases of right heart strain, which occurs commonly in patients with COPD; this may be misinterpreted as a sign of left ventricular failure. Indiscriminate use of D-dimer leads to false positive results and subsequent inappropriate (and potentially harmful) imaging. D-dimer should be obtained judiciously in cases where there is some clinical likelihood of venous thromboembolism.

Answer 16

COPD findings: flattened diaphragm, vertical heart, ↑ AP diameter, large focal lucencies indicating bullae Alternative diagnosis: PNA, PE, PTX -11 and 12 posterior rib

Answer 17

-COPD with right bullae

Answer 18

7.3- acidic -63 CO2- high -bicarb - 29 -> chronically compensating

Answer 19

-The decision to initiate one of these adjunctive therapies can be purely clinical. It can be based on overall assessment of work of breathing, or via direct measurement of arterial blood gases. -Mild exacerbation -Nasal cannula or venturi mask -Target O2 sat: 88-92% -Moderate-severe -NIPPV e.g. BiPAP* or CPAP -Contraindications: ________________________ -Rapid sequence intubation (RSI) -Severe exacerbation, respiratory arrest, mental status changes -Worsening oxygen, or worsening acidosis, despite BiPAP -NIPPV advantages: ↓ Work of breathing ↓ Intubation rates ↓ Mortality ↓ Hospital LOS ↓ Days in ICU -stay on bipap for at least 72 hrs no matter what

Answer 20

-O2 -beta agonist -corticosteroids (MAINSTAY) -but doesnt work fast -antibiotics- ceftriaxone in hospital, azithro at home (never really happens)

Answer 21

-discharge home (uncommon) -Mild-moderate symptoms -Responded well to therapy -Normal O2 on rest and EXERTION -Discharge with: steroids, bronchodilators, antibiotics -Follow up 1 week outpatient -admit: -Medical floors: -Low O2 with exertion/ambulation -ICU: -HD unstable -Intubated or biPAP -Severe acid base disturbance

Answer 22

-trigger- smoking -acute COPD tx- O2, albuterol +- ipa, steroids, antibiotics -non-invasive strat for work of breathing- nasal cannula and step up -88-92%

Answer 23

right lower lobe consolidation -silhouette sign

Answer 24

-airway/breathing: -supplemental O2 as needed -suction for aspiration -NIPPV or intubate for hypoxemia +- respiratory distress -circulation: -IV access and cardiopulmonary monitoring -crystalloid boluses for septic shock as needed -vasopressors for septic shock (nor -epi, vasopresin, epi) -tx: empiric antibiotics: -Regimen 1 = Azithromycin, Cefepime, Vancomycin OR -Regimen 2 = Cefepime, doxycycline, vancomycin OR -Regimen 3 = Azithromycin, Zosyn, vancomycin

Answer 25

-inflammation of the lung parenchyma -Alveolar airspaces are filled w/ exudate and inflammatory cells -Caused by infection (aspiration, inhalation, seeding) or chemical exposure -RFs: chronic lung dz, smoking, older age, immunocompromise -Classification based on pt and setting -MCC is strep pneumonia (no matter what) -Pneumonia is MCC of sepsis and septic shock!! -Cough (80-90%) -Fatigue / Malaise (90%) -Fever, chills (75%) -Sputum (60-65%) -Tachypnea (45-70%) -Pleuritic chest pain (39-49% -Dyspnea (67-75%) -ELDERLY often present ATYPICALLY -Confusion, AMS, Delirium (>50%) -Weakness -Lethargy -35% present w/o fever -Common physical exam findings -Tachycardia -Abnormal lung sounds (rhonchi, crackles, wheezing, decreased lung sounds) -Tactile fremitus -Egophony -Dullness to percussion

Answer 26

-type of infection: bacterial (typical or atypical), viral, fungal -pt health: health or unhealthy (co-morbid) -setting: CAP or HAP/VAP

Answer 27

-does not show up on gram stain -more likely diffuse rather than lobar -bullous myringitis -red throat -productive cough

Answer 28

-PCP -histoplasmosis -TB

Answer 29

-MRSA- recent flu that developed into bacterial

Answer 30

-If pt HEALTHY and MINIMALLY ILL -> no labs indicated!! -> clinical dx -Lab options include: -Viral swab testing -Respiratory cultures -If ICU admission, hx of MDRO, hx of MRSA/Pseuodomnas, recent parenteral antibiotics -CBC, CMP, VBG (↑ WBC with left shift)- if teetering on sepsis -Lactate- If signs of sepsis -Urinary s. pneumonia or legionella (GI symptoms and hyponatremic) antigen- Only in severe and if indicated -!A negative CXR does NOT rule out CAP -!A negative WBC does NOT rule out CAP -CXR in any pt with respiratory symptoms PLUS one or more: -≥ 65 years old -Abnormal vital signs -Abnormal lung sounds -CXR findings -LOBAR INFILTRATES: Air bronchograms, Bulging fissure sign -INTERSTITIAL PNEUMONIA- Diffuse ground glass opacities -CAVITATIONS (rare) -SILHOUETTE SIGN -RETROCARDIAC INFILTRATE -SMALL PLEURAL EFFUSIONS -Or.. nothing!- early on, dehydration, immunocompromised (no compensation) -other: -ECG -POCUS -CT chest- if concerned -pic shows left upper lobe- loss of cardiac sillohuette

Answer 31

-aspiration -upper lobes (usually would be lower)

Answer 32

legionella

Answer 33

TB miliary

Answer 34

A side note on cavitations: - Anaerobes can cause abscesses, especially if there is an air fluid level Staph aureus (IVDA) Pseudomonas Tuberculosis -dont send home -drain -can evade a vessel and cause bleeding

Answer 35

-65 year old with pneumonia- should you send them home? -> idk? use this tool! -Confusion = 1 pt -Uremia (BUN >20) = 1 pt -RR > 30 breath/min = 1 pt -BP (SBP <90 or DBP <60 mmHg) = 1 pt -Age > 65 = 1 pt

Answer 36

-Demographics -Co-morbidities -Presentation -Labs & Imaging

Answer 37

-NO CO-MORBIDITIES (CHOOSE ONE): -1. Amoxicillin 1 g oral every 8 hours. -2. Azithromycin 500 mg oral (day 1), followed by 250 mg oral every 24 hours (days 2-5) only if local pneumococcal macrolide resistance is <25%. -3. Clarithromycin 1,000 mg oral every 24 hours only if local pneumococcal macrolide resistance is <25%. -4. Doxycycline 100 mg oral every 12 hours -CO-MORBIDITIES (CHOOSE ONE): -1a. Amoxicillin-clavulanate 875 mg/125 mg oral every 12 hours AND -1b. Azithromycin 500 mg oral (day 1), then 250 mg oral every 24 hours (days 2-5). Or Doxycycline 100 mg oral every 12 hours. -2a. Cefpodoxime proxetil 200 mg oral every 12 hours or Cefuroxime axetil 500 mg oral every 12 hours AND -2b. Azithromycin or Doxycycline -3. Levofloxacin 750mg oral every 24 hours -> Monotherapy fluoroquinolone not first line recommendation!!!!

Answer 38

-Combination therapy with beta-lactam: -Ceftriaxone 1-2g IV QD OR Ampicillin + sulbactam 1.5-3g IV q6h (Unasyn) OR cefotaxime 1-2g IV q8h -PLUS Azithromycin 500mg QD (doxycycline can replace macrolide if allergy) OR… -Monotherapy with respiratory fluoroquinolone: -Levofloxacin 750mg IV/PO QD

Answer 39

-In non-severe CAP, even those with recent hospitalization, can defer treatment for these until positive test, or if high pre-test probability. -In severe CAP, give these -MRSA- Vancomycin or linezolid covers MRSA -Pseudomonas- Pip-tazo or meropenem or cefepime -PCP pneumonia- TMP/SMX

Answer 40

-PE* fever and dyspnea -ACS -CHF -Pulmonary abscess/emypema -Atelectasis -ARDS E.g. chronic toxicity from ASA -Cancer -Diffuse alveolar hemorrhage -Right sided endocarditis with septic emboli (IVDA) -Toxilogic or environmental -Tuberculosis -Low risk mimics: -Bronchitis, URI, minor asthma exacerbations

Answer 41

-Most CAP is caused by? -What can cause false negative CXR in PNA? -Who does NOT need a CXR? outpt, healthy -Risk factors for MRSA? recent hospitalization, intubation, recent flu -Pseudomonas? recent hospitalization -Tx for healthy outpatient CAP? betalactam - amox

Answer 42

-PE: -trachea deviation -JVD -decreased breath sounds -1st step -> emergent 14-16g needle decompression in the 2nd intercostal space midclavicular line -stabilize with chest tube in 5th intercostal space anterior axillary line

Answer 43

-SPONTANEOUS: -Primary- no underlying disease -> Think tall, thin, male smokers, Marfans, w/ blebs -Secondary- pts WITH underlying ds -> COPD, asthma, rarely TB, PCP -TRAUMATIC: -Iatrogenic- Bx, thoracocentesis, nerve blocks, central lines -Penetrating injury- Rib fractures, open wounds -Blunt chest injury -More likely to develop tension PTX due to 1-way valve -TENSION: -Any PTX can turn into a tension PTX -Shifting of mediastinal structures -DANGEROUS

Answer 44

-Sudden onset -Ipsilateral pleuritic chest pain -Dyspnea -Unilateral decreased breath sounds -↑ RR and HR -Lung collapse on CXR -Small: <20% or apical <1-2 cm from chest wall!!!!! -Minor symptoms -Observation with nasal oxygen -6-hour repeat CXR -No definitive treatment -Discharged home with close outpatient follow up. -Expiratory films preferred in PTX -no lung markings in the top left apical

Answer 45

need patient to stand upright for pneumo -left deep sulcus sign- so big -> air is pushing down on diaphragm

Answer 46

-obtain view of lung slide to assess -pleural side "ants on a log" = good -no pleural slide = BAD -M-MODE "seashore" is normal = good -M-MODE "barcode" is indicative of pneumo = BAD

Answer 47

-Small (simple) PTX -Observe + supplemental 100% O2 + repeat CXR 6 hours -Symptomatic or large (simple) PTX -Chest tube -TENSION, bilateral, expanding, or >20% lung -1st step is needle decompression 2nd ICS MCL -THEN definitive chest tube in 5th ICS Anterior axillary line -CT surgery consultation

Answer 48

-Should be diagnosed by CXR!!!!!!!!!! -Trachea deviation to the contralateral side -Patients will have severe dyspnea -Patients will be hypotensive -Decreased breath sounds on affected side

Answer 49

-set up: -IV access, vitals, monitor, -ECG- new arrythmia, sepsis -CXR -POCUS -airway/breathing: -airway usually intact unless altered -tachypnea, bibasilar dullness to percussion, hypoxic <90%, crackles +- wheezing are common -100% O2 by NRB -> NIPPV! -> intubate -circulation: -appear diaphoretic (skin is cold, clammy) -ECG to assess for new arrythmia -assess for new murmurs, S3 gallop, JVD, mucus membrane, peripheral edema, hepatomegaly -if HTN- consider nitroglycerin for preload and afterload reduction -If overloaded: Consider IV furosemide (not every pt with pulmonary edema is volume overloaded) -If hypotensive: Consider pressors. Think about causes of shock (MI, valvulopathy)

Answer 50

-Leading cause of hospitalization -Costs up to 50 billion a year -80% admission rate -Average LOS = 5 days -Mortality rate 10% per year -Heart cannot pump adequate blood -HFrEF (Systolic dysfunction) -Impaired contractility -Low EF <45% -Low cardiac output -HFpEF (Diastolic dysfunction) -Impaired relaxation of the heart leads to ↓ left ventricular filling and pulmonary congestion -LVEFF >50% -Can lead to systolic dysfunction

Answer 51

-Infection (e.g. pneumonia, sepsis) -!!Myocardial infarction or ischemia -Arrythmias -Uncontrolled hypertension -Excessive fluids, ↑ salt intake, renal failure -High output states (wide pulse pressure): -Profound anemia -Hyperthyroidism -Valvular disorders(severe aortic stenosis), dissection, PE, myocarditis/endocarditis -Fluid retaining medications (NSAIDs, oral hypoglycemic pioglitazone) -Medication non-compliance

Answer 52

-Dyspnea = MC -Orthopnea -Fatigue/Weakness -Leg swelling -Weight gain -Meds? -Diet? -Fevers? -PND? -Chest pain or RUQ pain? -Respiratory distress -Cool, clammy, diaphoretic -Tachycardia -Hypoxia -Low pulse pressure (<40mmHg difference) -Rales or crackles -S3 -JVD -Hepatojugular reflux -Ascites -Edema -New murmur (requires stat echo)

Answer 53

-ABG/VBG (pH, lactate) -B-type natriuretic peptide (BNP) is secreted by the ventricles in response to wall stress (↑ in CHF or PE) -Values <100 pg/mL has a negative predictive value of 98% -BNP>500pg/dL or NT-proBNP>1000pg/dL suggests acute heart failure syndrome -Troponin to evaluate for AMI -CBC -Anemia can cause high-output heart failure -Leukocytosis might indicate infection -CMP +Magnesium -Liver and renal function- BUN/creatinine > 20 = pre-renal failure (poor prognosis), Liver abnormalities from congestion (↑ bili, ↓ albumin) -Electrolyte abnormalities- Low K in chronic diuretics (thiazides, loop diuretics), Low Na in overload (poor prognosis) -Thyroid panel -VBG (pH, lactate)

Answer 54

-CXR can show cardiomegaly, pulmonary edema, pleural effusion, Kerley B lines, “batwing” congestion. R/o pneumonia, ptx -ECG with left axis deviation (hypertrophy). R/O ischemia, arrythmia -Ultrasound to look for 3 or more B-lines in one lung view, assess heart EF, wall motion, IVC -CXR- ABCDE -Alveolar edema (batwing) -Kerley B lines -Cardiomegaly -Dilated upper lobe vessels -Pleural effusion -echo: -checks for EF -see how hard the heart is pumping -B-lines in lungs represent increased fluid in the area -DDX: Pulmonary edema in CHF, pneumonia, pulmonary contusion

Answer 55

acute heart failure bag lining??- hilar infiltrates >> -pulmonary edema

Answer 56

-Monitor, IV, pulse oximeter, sit up -!Oxygen if needed (start with NRB 100%) -!NIPPV (BiPAP) helps pulmonary edema -!Nitroglycerin = 1st line in pts without cardiogenic shock! -Can't unload the LV if high afterload (HTN). Nitroglycerin reduces pre-load and afterload in hypertensive patients while redistributing fluid. -Start with 30mcg/min IV nitro -!IV diuretics (Furosemide (LASIX)) = in pts with fluid overload* -Total body volume overload: medication non-compliance, fluid restriction non-compliance with pedal edema, JVD, bibasilar crackles, plump IVC! -Removal of excess fluid can improve perfusion of heart and kidneys -Not all acute HF has total body overload (just fluid backed up in pulmonary system) -IV furosemide dose: double their total daily home dose as an IV bolus (often 40mg IVP) -*EXCEPTION: Flash pulmonary edema can occur in the setting of MI. This will NOT have fluid overload and does NOT require diuretics.

Answer 57

-Optimize oxygenation with NIPPV! -Optimize BP with vasopressors! -Norepinephrine! -Goal MAP 65-80 -Optimize contractility! with inotropes! -Dobutamine! can increase force of contraction and ↑ BP -Can sometimes exacerbate the hypotension, be prepared to start vasopressors such as dopamine or nor-epinephrine -Optimize volume status! (give IV crystalloid if intravascularly volume depleted, or, diuresis if overloaded) -Assess end-organ perfusion: mental status, UOP, skin mottling/temp, elevated lactate levels

Answer 58

ARDS -pancreatitis -aspiration

Answer 59

-ARDS/Non-cardiogenic pulmonary edema= Acute, diffuse, inflammatory lung injury -Poor lung oxygen exchange due to fluid in lung -Some of the sickest! pts we see in the ED! -ARDS is a not a primary disorder -> SECONDARY to other illnesses: -Sepsis MC! -INDIRECT: Pancreatitis, drug overuse, transfusion related injury, DIC -DIRECT: Inhalation or burn injuries, pneumonia, toxin inhalation, lung contusions, drowning -Hypoxemia!, tachycardia, dyspnea, diffuse crackles on exam -PaO2/FiO2 ratio < 300!!!! (the worse the ratio, the more severe) -CXR = diffuse pulmonary edema!!! bilaterally that is NOT explained by cardiac failure -must r/o heart causes -Immediate tx: High flow oxygen, IV fluids, PEEP!!, tx of underlying cause -Supportive care, no direct therapy for reversal of ARDS -Admit to the ICU!!!

Answer 60

-Typically, sudden onset -Wheezing -Hives (80%) -Vomiting / diarrhea are common -Hypotension -Oropharyngeal edema -angioedema -urticaria -erythema -derm 90% -tx: -!Epinephrine saves lives -0.3 - 0.5 mg of 1:1,000 IM q5m x 3 -(Peds is 0.01 mg/kg) -Anterolateral thigh better than deltoid -IM > subq -Blue to sky, orange to thigh -Other medications to give -!Antihistamine (Benadryl) – blocks further antihistamine release -!H2 blocker (famotidine)– blocks bradykinin -!Steroids (dexamethasone) – block rebound anaphylaxis -IV fluids – improve hypotension -Glucagon – beta blockers can prevent effect of epinephrine, give to patients on BB

Answer 61

ANGIOEDEMA -Histamine or bradykinin mediated -Transient localized, non pitting swelling -Hereditary, acquired, ACE-I, TPA

Answer 62

lung cancer

Answer 63

Upon questioning, the patient reported that he had been chewing on the plastic end of a mechanical pencil 1 week before presentation and had choked on a small piece, which he thought he had swallowed Otolaryngology was consulted Elective rigid bronchoscopy for possible FBA. A small plastic object surrounded by granulation tissue and mucopurulent secretions was found at the left secondary bronchus and was removed. His postoperative course was uncomplicated, and he was discharged home after few hours of observation.

Answer 64

POCUS in acute PE RV wall hypokinesis, RV dilation, RA dilation, paradoxical septal systolic motion and dilated IVC with lack of respiratory collapse “D” sign -EKG Sinus tach RBBB Poor R wave progression TWI in precordial leads CXR - normal CBC (WBC 10) CMP (Cr 1.2) COAGS, T&S TROPONIN (neg) BNP (221) VBG (pH 7.38, PCO2 48, Lactate 1.4) -RV becomes bigger than LV due to massive PE blockage -> LV changes shape (D) bc its pushed -> D sign -giant black spot is the PE

Answer 65

-displaced ETT -obstruction along circuit -pneumothorax -equipment failure