Airway & Respiratory Emergencies Flashcards
1
Q
2 types of airway obstruction & outcomes
A
partial or complete
partial often->complete if not cleared
complete->respiratory arrest if not cleared
4 mins from complete obstruction to brain damage
(U) in pre-hospital setting
2
Q
Types of airways
A
oral airways
nasal
laryngeal mask
3
Q
Foreign body aspiration in a Toddler sxs
A
- persistent cough, unilateral wheezing
- NO URI sxs (can be tough)
- ↓breath sounds
- often not seen on CXR
- post-obstructive atelectasis, pneumonia
- not always down right mainstem
4
Q
Emergency Room at Trauma Center
A
LeForte fractures
Basilar skull fractures
5
Q
Burn Center
A
Airway edema
6
Q
Anaphylaxis & Acute Allergic Rxns
A
Severe hypersensitivity rxn w/ CV collapse & resp comp
7
Q
Anaphylaxis & Acute Allergic Rxns: Pathophysiology
A
- Antigen-antibody binds to mast cells
- IgE mediated histamine release
- increased vascular permeability, vasodilation, bronchial constriction
- increased mucous gland secretion
8
Q
Anaphylaxis & Acute Allergic Rxns: (C) causes (4)
A
- Antibiotics
- ASA & NSAIDs
- shellfish, nuts, eggs, milk
- hymenopytera stings
9
Q
Anaphylaxis & Acute Allergic Rxns: clinical features (6)
A
onset: secs to hrs angioedema tightening in throat/chest laryngeal swelling & bronchial spasm, hoarseness, stridor, wheezing respiratory distress & apnea
10
Q
Anaphylaxis & Acute Allergic Rxns: Dx
A
clinical
check airway, BP, SaO2, lungs immediately
11
Q
Dx of anaphylaxis & Acute Allergic Rxns
A
clinical
check airway, BP, SaO2, lungs immediately
12
Q
Anaphylaxis & Acute Allergic Rxns: Tx (8)
A
1- airway management 2- oxygen 3- antihistamines: H1 (diphenhydramine or hydroxyzine), H2 (cimetidine) 4- Beta2 agonists (albuterol) 5- steroids (methylprednisolone) 6- endotracheal intubation 7- surgical airway 8- If hypoTN: IV bolus and epi
13
Q
Angioedema
A
(S) to urticaria but w/
LARGER EDEMATOUS AREAS,
INVOLVE BOTH DERMIS & SUBCUTANEOUS,
frequently involving the head & neck
14
Q
Causes of angioedema (3)
A
- hereditary or acquired
- insufficient synthesis of C1esterase inhibitor (rare, autosomal dominant)
- ACE inhibitors
15
Q
Tx of angioedema (5)
A
Airway management
Supportive
Plasma concentrate of C1 esterase inhibitor
Epinepherine, antihistamines, steroids
Danazol:↑synthesis of C1 esterase inhibitor
16
Q
Retropharyngeal Abscess: definition
A
- a localized collection of pus in the retropharyngeal space
- rare
17
Q
Retropharyngeal Abscess: caused by (4)
A
- mixed gram negative & anaerobic bacteria
- tonsillitis
- otitis media
- pharyngeal trauma
18
Q
Retropharyngeal Abscess: signs & symptoms (9)
A
"FOND M CATS" Fever Odynophagia Neck swelling Drooling Meningismus Cervical adenopathy Airway obstruction Torticollis Stridor
19
Q
Retropharyngeal Abscess: dx
A
clinical
soft tissue lateral neck x-rays (gas, mass)
CT Neck
20
Q
Retropharyngeal Abscess: tx (4)
A
Airway Management
Antibiotics
Admission
Surgical Drainage
21
Q
Epiglottitis
A
infection of the supraglottic structures including the epiglottis, lingual tonsillar area, epiglottic folds & false vocal cords
22
Q
Epiglottitis epidemiology
A
age 2-7 before H. influenza B vaccine
stem occasionally in adults
HiB, Strep, Staph (not 100% protected by vaccine)
rare
23
Q
Signs and Sxs of Epiglottitis
A
abrupt onset over several hours fever stridor toxic appearance dysphagia odynophagia (painful swallowing) drooling tripod position altered LOC cyanosis airway obstruction
24
Q
Epiglottitis dx
A
-best if done clinically due to the tenuous airway
NEVER stick a tongue blade in throat
-soft tissue lateral neck x-ray if very stable
25
Epiglottitis tx
IMMEDIATE attention to control the airway
-Antibiotics once airway is secured
3rd generation cephalosporin
26
Croup (Laryngotracheobronchitis) description & usual cause
(U) benign, self limited inflammatory condition of the trachea below the level of the vocal cords (subglottic),
(U) caused by parainfluenza virus
27
Croup (Laryngotracheobronchitis) epidemiology
age range 6 months to 3 years
can see as old as 15 years
increased in winter
28
Croup (Laryngotracheobronchitis) signs and sxs
```
2-3 day history of URI
low grade fever
gradual worsening "barking seal" cough, especially at night
stridor
dyspnea
retractions
tachypnea
```
29
Croup (Laryngotracheobronchitis) Diagnosis
Clinical
| PA CXR shows "STEEPLE SIGN" (but not very sensitive or specific)
30
Croup (Laryngotracheobronchitis) treatment
airway management
cool mist
oxygen if needed
nebulized epinephrine (must observe for 3-4 hours after tx)
steroids: prednisolone 1mg/kg
dexamethasone (Decadron) .15 to .6 mg/kg IM or PO (max 10 mg), lasts up to 56 hrs
31
Whooping Cough: cause, prevention, high risk groups
a respiratory emergency
(C): Bordetella pertussis, a gram negative aerobe
cycles every 4 to 5 years
vaccine (DPT) does not give complete protection after about 10 years
-unvaccinated infants & toddlers at highest risk
32
Whooping Cough: signs and symptoms
```
URI sxs in early stage
fever usually absent
paroxysms of coughing in later stage
inspiratory stridor in younger patients
post-tussive vomiting
```
33
Whooping Cough diagnosis, transmission, risks, tx
- by nasopharyngeal swab on special culture media
- highly contagious in early stage
- risk of SIDS & airway compromise in unvaccinated kids
- need to pretreat unprotected contacts (Erythromycin/Azithromycin)
34
Bronchiolitis (RSV) def
clinical syndrome in infancy characterized by rapid respiration, chest retractions & wheezing
35
Bronchiolitis (RSV) epidemiology
Winter
Male>female
0-2 years range (peak 2-6 months)
Respiratory Syncital Virus (RSV): most common cause
36
Bronchiolitis (RSV) pathophysiology
bronchiolar obstruction from submucosal edema & mucous plugging
37
Bronchiolitis (RSV) signs & sxs
```
runny nose, sneezing
low grade fever
dyspnea
tachypnea
intercostal retractions
wheezing
cyanosis
apnea
```
38
Bronchiolitis (RSV) diagnosis
-clinical
-CXR-hyperinflated lungs
pulse oximetry usually shows hypoxia
-viral cultures/fluorescent -monoclonal antibody testing of NP swabs
39
Bronchiolitis (RSV) treatment
```
Airway management, primarily supportive
Mild cases [alert, playful, feeding well, RR<50, no retractions, no hypoxia, w/no associated significant illness] can be observed at home,
All others should be admitted
Oxygen
Beta 2 agonists
Ribavirin for severely ill or intubated
```
NO steroids
40
Asthma definition
a condition characterized by paroxysmal attacks of reversible bronchospasm, mucous pluggint and inflammation of the tracheobronchial tree
41
Asthma acute exacerbation signs & symptoms
- progressive dyspnea
- chest tightness
- wheezing
- cough
- obvious respiratory distress
- auscultation of wheezes
- use of accessory muscle or nasal flaring
- altered LOC
- don't be fooled by the "quiet chest"
42
asthma acute exacerbation tx
airway management
oxygen
Beta 2 Agonists (bronchodilators): nebulized (SVN) (Albuterol)
Steroids: PO-prednisone, prelone; IV-solumedrol
Anticholinergics: nebulized (atrovent, ipratropium bromide)
admission or discharge decision within 1 hour
43
Usual protocol if asthma acute exacerbation
stacked SVN treatments w/bronchodilators:
- .5 cc albuterol in 2.5 cc normal saline, 3 txs given q 30mins
- peak flow rate before 1st & after 3rd tx
- determine if steroid therapy is needed
- look for underlying infection
44
Asthma acute exacerbation: questions to ask?
```
admit or discharge?
how much baseline respiratory distress?
vulnerable population?
how much improvement with each SVN?
underlying factors?
able to get follow-up care?
reliable to follow instructions for out-pt tx?
```
45
COPD & Emphysema: physiological what is going on in both
V/Q mismatch=areas of perfusion are not being ventilated
| -wCO2 retention, hypoxic drive has long been lost & CO2 drive is being lost, these are very sick patients
46
COPD vs. Emphysema
COPD="blue bloaters", more bronchospasm & mucus plugging
emphysema="pink puffers", more loss of alveolar architecture
(U) some combination
47
Emphysema & COPD epidemiology
older population
| smokers
48
Emphysema & COPD signs &sxs
- progressive dyspnea, may have been having dyspnea for days before presenting to the ED!
- chest tightness
- wheezing
- cough
49
Emphysema & COPD dx of exacerbation
- obvious respiratory distress
- wheezing
- use of accessory muscles
- altered LOC-ominous
- don't be fooled by the "quiet chest"
- change in sputum production & color
50
Emphysema & COPD tx
airway management
oxygen
Beta 2 agonists(bronchodilators):
nebulized (SVN) (albuterol)
Steroids: PO (prednisone, prelone), IV (Solumedrol)
Anticholinergics: nebulized (atrovent-ipratropium bromide)
Antibiotics
Admission or discharge decision within 1 hour
Very hard to extubate
51
Emphysema disposition/admission rate
higher admission rate than asthma
- older population
- more comorbid conditions
- more damage to the lungs
52
Pneumonia
inflammation of the lung caused by infection which causes the alveoli to become filled with pus so that air is excluded
53
Pneumonia signs & sxs (5)
```
fever
cough
dyspnea
pleuritic chest pain
respiratory failure
```
54
Pneumonia diagnosis (7)
```
auscultation
CXR
pulse oximetry
blood gasses
CBC
blood cultures
sputum Gram stain, C&S
```
55
Pneumonia treatment (5)
```
Airway management
Oxygen
Antibiotics
Beta 2 agonists
Analgesics
```
56
Congestive Heart Failure/Pulmonary Edema: definition and cause
inability of myocardium to adequately perfuse end-organs->fluid accumulation, arterial vasoconstriction-> further pump failure
most (C) cause=coronary ischemia
most (C) cause of right HF=left HF
57
CHF/PE (C) causes (4)
- MI
- valvular dysfxn (high output failure w/regurgitant lesions, stenosis lesions get critical very fast)
- cardiomyopathy (viral)
- systemic HTN (wall thickening then hypoperfusion
58
CHF/PE signs & sxs (5)
```
dyspnea
orthopnea
paroxysmal nocturnal dyspnea
fatigue
peripheral edema
```
59
CHF/PE diagnosis (8)
```
diaphoresis
tachypnea
tachycardia
pulmonary rales or wheezing
JVD-hepatojugular reflux
hepatomegaly
pitting peripheral edema
pulse oximetry
```
60
CHF/PE tx (5)
- Airway management
- Oxygen
- Vasodilators: nitrates (SL, topical, IV)
- Diuretics: furosemide (Lasix) 20-40 mg IV
- Inotropic agents (B1), dobutamine
61
Pneumothorax def
any breech of lung surface or chest wall allowing air to enter the pleural cavity, causing the lung to collapse
62
Pneumothorax signs & sxs (3)
- chest pain on side of collapsed lung
- dyspnea
- occasionally cough, but absence of other URI symptoms
63
Large pneumothorax dx (8)
- Decreased breath sounds
- tachypnea
- tachycardia
- TRACHEAL DEVIATION TO OPPOSITE SIDE
- HYPOTENSION
- cyanosis
- marked respiratory distress
- CXR
64
Pneumothorax tx
tx based on % involvement on CXR & overall pt presentation
<15-20% involvement: observation only, repeat CXR in 48 hrs
20% or more=intervention
- needle decompression
- simple aspiration
- tube thoracostomy (chest tube)
65
Pulmonary Embolism
venous thrombi dislodge & travel to the pulmonary arteries where they cause occlusion
-presenting signs & symptoms depend on how occluded pulmonary vasculature is & pre-existing cardiopulmonary dz
66
PE sxs
3 most common: dyspnea (81%), pleuritic chest pain (73%), cough (60%)
other sxs: any type of chest pain, wheezing, chest wall tenderness, anxiety, hemoptysis
67
PE: predisposing factors (6)
```
immobility (best rest, traction, etc)
heart dz
CA
estrogen therapy
previous DVT or PE
hypercoagulability
```
68
PE dx work-up
- almost always rule out MI so need ECG, cardiac enzymes
- pulse ox & ABGs controversial
- CXR
- V/Q scan (provides distribution of pulmonary blood flow by visualizing radioactivity after IV injection of radiolabeled albumin microaggregates)
- D-Dimer
- CT scan of chest
69
V/Q scan report
reported as low, intermediate or high probability
[low or intermediate DOES NOT RULE OUT]
high probability in a pt with strong risk factors->initiate therapy
70
Controversial PE workup
do a work-up for LE DVT?
- serial impedance plethysmography
- Doppler ultrasonography
gold standard dx test=pulmonary angiography, but it is invasive and risky (morbidity rate of 4%), so RARELY DONE
71
PE tx
```
supportive care
oxygen therapy
anticoagulation therapy
intensive monitoring
pain relief
surgical embolectomy
vena cava filter (Greenfield filter)
```
