12 - Pulmonary Emergencies

Question 1

Pneumothorax

Answer 1

• Air gets trapped between the chest wall and the lung. Increased pressure causes the lung to collapse
• Air gets in through holes in the lungs or the chest

Question 2

Causes of pneumothorax

Answer 2

• Trauma
• COPD (or any chronic lung disease)
• Infection
• Cancer
• Spontaneous

Question 3

Hemopneumothorax

Answer 3

• When the chest is filled with blood and air

Question 4

Tension pneumophorax

Answer 4

• When pressure increases to the point where there is tracheal shift and cardiac compromise. Usually secondary to penetrating chest trauma

Question 5

Pneumothorax signs and symptoms

Answer 5

• Pleuritic chest pain
• Dyspnea
• Cough
• Sub-q emphysema
• Unilateral decrease in breath sounds

Question 6

Spontaneous pneumothorax risk

Answer 6

• In tall thin males
• Smokers
• Pneumonias
• Recurrence rate 20-50%

Question 7

**Treatment of pneumothorax **

Answer 7

• Needle decompression
• Chest tube
• O2

Question 8

Flail chest

Answer 8

• When multiple ribs are broken and separated from the rest…results in paradoxical movement

Question 9

Pulmonary embolism risk factors

Answer 9

• Obesity
• Surgery
• Smokers
• Hormone use
• Bed ridden/long travel
• Trauma
• Cancer
• Clotting d/o

Question 10

PE

Answer 10

• +90 % start in LE; some from abdomen and UE
• 70% missed at initial presentation
• 60% of pts that die in hospital have PE (not necessarily cause of death)

Question 11

PE signs and symptoms

Answer 11

• Dyspnea (90%)
• Chest pain (67%)
• Hypoxia
• Tachypnia

Question 12

Chest x-ray

Answer 12

• Nonspecific abnormalities in 75%
• Hamptoms hump (wedge shaped consolidation)
• Atelectesis
• Enlarged Heart
• Can’t rule in or out based on CXR*

Question 13

PE Wells Prediction Rule

Answer 13

• Table 1. Modified Wells Prediction Rule for Diagnosing Pulmonary Embolism:
• Clinical Evaluation Table for Predicting Pretest Probability of Pulmonary Embolism*
• **CAN TELL YOU THE RISK FOR PE **
• Previous PE or DVT
• Heart rate over 100
• Recurrent surgery/immobilization
• Clinical signs of DVT
• Alternative diagnosis less likely
• Hemoptysis
• Cancer (treated in last 6 months)

Question 14

D-dimers

Answer 14

• Overly sensitive
• Increased in pregnancy, trauma, surgery, inflammatory reactions and even multiple sticks
• If low, chance of PE very low

Question 15

V/Q scan

Answer 15

• Must be able to cooperate with test
• No contrast needed
  o Normal (1/3)
  o Low (20%)
  o Intermediate
  o High (80%)
• You will do this on people who can’t get a CAT scan

Question 16

CT and PE

Answer 16

• Need IV and renal function
• 95% sensitive
• 1000 chest CTs done to r/o PE; 17% found other issues that needed to be addressed

Question 17

Pulmonary contusion

Answer 17

• Most common chest injury in kids
• Usually resolves in 3-5 days
• 36% have nml initial cxr (lags)
• Decreased lung function for 4 years; resembles fibrosis
• Significant ones can lead to ARDS, pneumonia
• If young/healthy, not usually fatal

Question 18

Pulmonary contusion treatment

Answer 18

• Good chest toileting (take deep breaths)
• Empiric abx don’t work; get sputum if pneumonia and treat specific
• Support with O2/intubation if needed
• Small amount of peep
• Treatment (what the slides say)
  o Anticlotting agents
  o Thrombectomy

Question 19

Aortic rupture

Answer 19

• 90% die on scene
• If they live to the ER, you don’t want to miss it
• Widened mediastinum +50% sensitive and specific
• CT close to 100% sensitivity

Question 20

Signs and symptoms of aortic rupture

Answer 20

• Hypotension
• Substernal or scapular pain
• Dyspnea or dysphasia
• Strider
• Only 50% have external signs of chest trauma

Question 21

**CHF signs and symptoms **

Answer 21

• Heart fails to keep up with blood; fluid backs up into body and lungs
• s/s are dyspnea, cough, sounds wet, increased l.e. edema
• # 1 admission diagnosis in >65 y/o
• 10% of population >75
• Mortality significant (3-5 years)
• BNP

Question 22

CHF treatment

Answer 22

• Diuretics
• O2
• Nitro
• Fans decrease dyspnea
• Treat underlying causes
• CPAP/BIPAP acutely

Question 23

Pneumonia

Answer 23

• **Pneumonia is a common disease to chase after surgery/immobility/intubation*

Question 24

Pneumonia treatment

Answer 24

• Antibiotics
• O2
• Nebulizers

Question 25

COPD

Answer 25

• Usually secondary to smoking
• “Set off” by infection, exertion, allergy, changes in weather
• Treatment nebs, oxygen (gentle), steroids, bipap

Question 26

Case Study 1

Answer 26

Case presentation
o 50-year-old male with right lateral back pain and difficulty breathing
o Steps in the winter
o Denies other injury
o Non-smoker
o Extreme pain with movement, palpation on tender area or breaths
o When asked “are you sort of breath” replies “it hurts to breath”

Initial evaluation
o Likely to have a bruised rib or broken rib

Chest x-ray
o Along the lateral boarder, there’s no lung markings
o Not a full pneumo, just a partial (30-40%)

Treatment
o Ketamine
o Chest tube
o Recovery

Never found a fractured rib

Question 27

TEST QUESTION

Answer 27

CPAP and BIPAP – Read these