Chest Pain To ARDS Flashcards
Pain 2/2 to inflamation ion of the parietal pleura
Following a URI, Pneumonia or infection,
S/S: local sharp pain that increases with cough, sneezing, or deep RR that radiates to the ipsilateral shoulder
+/i a friction rub on lung auscultation
D/o and Tx?
Plurisy/ Pluertitis
Tx the underlying condition
+Indomethacin and Codine for cough suppression
Abnormal fluid in the lung space
S/s dyspnea, cough, respirophasic pain, Increased dullness to percussion, decreased RR sounds
Thoacocentesis reveals milky white fluid with a low pH and positive Gram Stain
Empyema
Dx Thoracocentesis (Dx and Tx)
-if unknown cause or
Clinically: bilateral effusion of CHF (obvious cause)
Tx: ABX and Tube Thoracostomy
What is the Tx for frequent recurrent pleural effusions
Pluerodesis
Abnormal fluid in the lung space
S/s dyspnea, cough, respirophasic pain, Increased dullness to percussion, decreased RR sounds
Thoacocentesis reveals sterile pleural fluid
D/o and Tx?
Uncomplicated pleural effusion
Dx Thoracocentesis (Dx and Tx)
-if unknown cause or
Clinically: bilateral effusion of CHF (obvious cause)
Tx: ABX for treatment of underlying pneumonia
Abnormal fluid in the lung space
S/s dyspnea, cough, respirophasic pain, Increased dullness to percussion, decreased RR sounds
Thoacocentesis reveals fluid with low glucose (less than 60) and low pH (<7.2) with negative Gram stain
D/o and Tx?
Complicated Plerual Effusion
Dx Thoracocentesis (Dx and Tx)
-if unknown cause or
Clinically: bilateral effusion of CHF (obvious cause)
Tx: ABX and tube thoracotomy
Effusions due to infection refractory to antibiotics and drainage require
surgical debridement.
Chest centesis reveals triglycerides >110 mg/dl
Think?
Chylothorax exudative pleural effusion
Esophageal rupture leads to what types of effusion
Exudative
Centsesis reveals high amylase with a left sided effusion, think?
Pancreatitis, and or esophageal rupture
Plural effusion with frank pus in the plural space with a postive gram stain and refractory fevers
Think ? Tx?
Empyema (Exudative Plural effusion)
Tx Prompt Drainage and ABX
Chest centesis reveals an empyma (infection) with cholesterol crystals
Think
Exudative Plueral Effusion 2/2 Rheumatoid
Plueral centesis reveals e elated protein with no other findings think>?
TB (exudative effusion)
What is the fluid level requirement for centesis of the chest
Need at least 1 cm of fluid in the decubitus view to perform a blind centensis
Otherwise centesis should be guided by U/S
What is the lowest level of fluid that can be detected by CT
(Plueral effusion)
10 Ml of fluid
Difference between a hemorrhagic plural effusion and a hemothorax
Hemorrhagic pleural effusion—mix of blood & pleural fluid
Hemothorax—gross blood in pleural space
—Pleural fluid hct : blood hct > 0.5
difference of Empyema vs chylous effusion
After centrifuge
Empyema—clear fluid over white cells
Chylous effusion—persistently turbid
—Chylomicrons & elevated triglyceride level >100mg/dL
Define Lights Criteria
Effusion is exudative if
- Plerual fluid protein/ serum protein is greater than 0.5
- Plueral effusion fluid LDH/ serum LDH is greater than 0.6
- Plueral Fluid LDH is greater than 2/3 the ULN of the serum LDH.
What is the most common causes of exudative p. effusion?
CA
Tall thin male aged 2-40, with a hx of smoking. Euchroid proportions (marfans)
S/s sudden onset unilateral chest pain, at rest or awoken from sleep
With tachyHr, diminished breath sounds decreased tactile fremitus, and hyper resonance unilateral
D/o? CXR? Tx?
Simple Pneumothorax
CXR: Visceral Pleural Line
(Late complicated findings are tracheal shift, medistinal shift)
Tx: Needle decompression and possible chest tube
If less than 3cm can be treated outpt with f/u at 24hrs
> 3cm needle D to chest tube
What conditions place a patient at risk of developing 2nd PneumoTHX ?
complication of pre-existing lung disease
- COPD
- asthma
- cystic fibrosis
- tuberculosis
- pneumocystis pneumonia
- interstitial lung disease
Pts at increased risk of Simple Tension Pneumo should be counseled to…
Stop smoking, avoid high alt. Or scuba diving
What is the Tx for recurrent tension Pneumos
Resection of blebs and pluordesis
What is the O2 delivery of a NC
FiO2: 22-50%
with flow rate of 1-6 liters/min
What is the O2 delivery of a simple face mask
Simple face mask can deliver oxygen concentrations of 40% to 60%
with flow rates from 6 to 10 L/min
What is the O2 delivery of a Venturi Mask
Venturi principle masks 24% to 60% with flow rates from 4 to 12 L/min
What is the O2 delivery of a NRB
Non-rebreather mask with reservoir: FiO2: 50-100%
with flow rates from 10 to 15 L/min
What is the O2 delivery of a High Flow NC
High-flow nasal cannula 21-100% fi02 atflowrates of up to 60 liters/min
Life threatening abnormal gas exchange with a PaO2 less than 60, SaO2 less than 90%
or a PaCO2 >45mmHg
Think ?
Acute Resp failure
Primary causes of Hypoxemic Resp Failure
ARDS Pneumonia Acute lobar acetlectasis Chronic Pulm Edema Lung Contusions
Common causes of Primary hypercapnic Acute resp. Failure
COPD Asthma GBS Rx MG Hypomagnesemia OHS
Asterixis is a sign of…
Metabolic encephalopathy
Seen in acute Resp failure
As well as CKD, CHF, Liver failure
A pt is at risk of Hypercapnic Resp Failure, and has an SpO2 less than 88.. what is the next intervention
Start O2 with NC 2-4 L.min on 28%
O2 target is 92%
+/- bronchodilator as needed
Obtain ABG
A pt is at risk of Hypercapnic Resp Failure, and has an SpO2 greater than 88.. what is the next intervention
No O2 Tx is needed, Monitor and consider ABG
A pt is not at risk of hypercapnic resp failure and has an SPO2 less than 85%, what is the best Tx
Start O2 4L.min NC Or 5-10L with a nimble mask Or 15L/min of NRB
O2 goal of 92-96%
Obtain ABG
A pt is not at risk of hypercapnic resp failure and has an SPO2 is less than 91%, what is the best Tx
Start 2-4 L NC or other suitable O2 delivery with a O2 goal of 92-96%
Consider ABG
What is the 1st line O2 tx in pts with COPD
NIPPV (BiPAP)
What are the 7 indications for intubation
- Hypoxemia despite O2 tx
- Upper Airway Obstruction
(Laryngeal edema/ burns) - Impaired Airway Protection
(Less than 8 intubate) - Inability to clear secretions
- Progressive general fatigue, tachypnea, use of accessory muscle use or AMS
- Apnea
- Severe hypoxemia at presentation
Right stem intubation leads to what ADE
Atelectasis of the contralateral lung and over distention of the intubated lung
Ventilated pt has SubQ emphysema
Pneumomediastinum and su Plueral air cysts
Think ?
Barotruama
Tx: hypoventilation to avoid baratura a
What is the general supportive care for Acute Respiratory Failure
Nutrition, Monitor electrolytes, and ovoid oversedation, PPI to prevent ulcers and DVT prophylaxis
Non cardiogenic pulmonary edema that leads to acute hypoxemia and RR failure
Resp Distress onset within 1 wk of insult, profound dyspnea, hypoxemia refractory to tx, labored RR, tachypnea, crackles, plus multiple organ failure
CXR: Bilateral ground glass appearance that spares the costophrenic angles with a NML hr size +bronchograms
WIth a PaO2 and FiO2 ration less than 300.
MC 2/2 sepsis, diffuse pneumonia, aspiration, or trauma
Think? Tx?
ARDS
Tx: Identify & treat underlying illness/injury
—Broad spectrum antibiotics for sepsis and/or infection
General supportive care
Tracheal intubation and mechanical ventilation
—The lowest levels of PEEP (used to recruit atelectatic alveoli) with supplemental O2 (FiO2 <60%) to maintain SaO2 >88%
—Low tidal volume (ideal weight based 6 ml/kg)
Prone positioning
Monitor cardiac & other organ functions
Describe the pathological progression of ARDS
Injury to the lungs, capillaries, and endothelial cells
Leads to increased vasc. Permeability and decreased production/activity of surfactant
Result: interstitial and alveolar pulmonary edema, alveolar collapse/atelectasis, and hypoxemia
What should you rule out before making the Dx of ARDS
Pulm. Edema 2/2 HF
Define Mild ARDS
PaO2/FiO2 ration between 200 and 300
Define Moderate ARDS
P/F ration above 100 and less than 200
define Severe ARDS
P/F ration less than 100
Hyaline membrane disease in infants and nearly all preterm pts
Caused by deficient pulmonary surfactant in an immature lung
Rapid accumulation of neutrophils in the lung that lead to pulmonary edema and actelectasis leading to cytokines inflammatory response
S/s tachypnea, cyanosis soon after birth, nasal flaring, with retractions and profound hypoxemia
Think ? CXR? Tx?
Neonatal Resp. distress Syndrome
CXR: low lung volumes,a nd classic reticulgranular ground glass appearances with air bronchograms
Tx: Prevention with antenatal steroids at 23-34 weeks gestation
Peep and Nasal CPAP leading up to intubation with exogenous surfactant admin.
Intubation criteria is requiring a FIO2 of 0.40% or higher to maintain an O2 sat of 90 or above or any apnea
