12 - Pulmonary Emergencies Flashcards
Pneumothorax
- 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
Causes of pneumothorax
- Trauma
- COPD (or any chronic lung disease)
- Infection
- Cancer
- Spontaneous
Hemopneumothorax
- When the chest is filled with blood and air
Tension pneumophorax
- When pressure increases to the point where there is tracheal shift and cardiac compromise. Usually secondary to penetrating chest trauma
Pneumothorax signs and symptoms
- Pleuritic chest pain
- Dyspnea
- Cough
- Sub-q emphysema
- Unilateral decrease in breath sounds
Spontaneous pneumothorax risk
- In tall thin males
- Smokers
- Pneumonias
- Recurrence rate 20-50%
**Treatment of pneumothorax **
- Needle decompression
- Chest tube
- O2
Flail chest
- When multiple ribs are broken and separated from the rest…results in paradoxical movement
Pulmonary embolism risk factors
- Obesity
- Surgery
- Smokers
- Hormone use
- Bed ridden/long travel
- Trauma
- Cancer
- Clotting d/o
PE
- +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)
PE signs and symptoms
- Dyspnea (90%)
- Chest pain (67%)
- Hypoxia
- Tachypnia
Chest x-ray
- Nonspecific abnormalities in 75%
- Hamptoms hump (wedge shaped consolidation)
- Atelectesis
- Enlarged Heart
- Can’t rule in or out based on CXR*
PE Wells Prediction Rule
- 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)
D-dimers
- Overly sensitive
- Increased in pregnancy, trauma, surgery, inflammatory reactions and even multiple sticks
- If low, chance of PE very low
V/Q scan
- 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
CT and PE
- Need IV and renal function
- 95% sensitive
- 1000 chest CTs done to r/o PE; 17% found other issues that needed to be addressed
Pulmonary contusion
- 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
Pulmonary contusion treatment
- 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
Aortic rupture
- 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
Signs and symptoms of aortic rupture
- Hypotension
- Substernal or scapular pain
- Dyspnea or dysphasia
- Strider
- Only 50% have external signs of chest trauma
**CHF signs and symptoms **
- 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
CHF treatment
- Diuretics
- O2
- Nitro
- Fans decrease dyspnea
- Treat underlying causes
- CPAP/BIPAP acutely
Pneumonia
- **Pneumonia is a common disease to chase after surgery/immobility/intubation*
Pneumonia treatment
- Antibiotics
- O2
- Nebulizers
COPD
- Usually secondary to smoking
- “Set off” by infection, exertion, allergy, changes in weather
- Treatment nebs, oxygen (gentle), steroids, bipap
Case Study 1
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
TEST QUESTION
CPAP and BIPAP – Read these
