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Rosen's > Dyspnea > Flashcards

Dyspnea Flashcards

1
Q

Definitions: Allergy vs Urticaria vs Angioedema vs Anaphylaxis

A

Allergy: Hypersensitivity reaction after exposure to allergen

Urticaria: Systemic reaction to an allergen which can include hives, itchiness

Angioedema: Sudden swelling of a subq or cutaneous membrane due to vascular permeability and vasodilation
- can be allergy induced or not (ie med induced, hereditary)

Anaphylaxis: Life-threatening, type 1 hypersensitivity reaction to previously sensitized allergen
- non-immunologic to first time exposures likely due to mast cell degranulation (ie first time taking NSAIDs)

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2
Q

ROSENS BOX

4 types of Gell and Coombs immune reaction classification:

A

TYPE 1 = immediate hypersensitivity
- Binds to IgE –> mast cell degranulation –> minutes to desensitize
- most common

TYPE 2 = Cytotoxic antibody rxn
- Antigen binds to antibody (IgG/IgM) –> cell lysis
- ex: transfusion reaction ; Rh incompatibility

TYPE 3 = Immune complex mediated
- IgG/IgM binds to antigen –> forms immune complex –> deposits in vessel cells –> local infl –> infl and tissue injury
- Seen in SLE ; serum sickness

TYPE 4 = Cell mediated delayed hypersensitivity
- NO antibody involved
- lymphocytes see antigen and recruit more antigen
- ex: contact dermatitis, SJS, TEN

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3
Q

Risk factors for having anaphylaxis (2 categories, 12 total)

A

Age and Sex
- pregnant woman
- infants
- teenagers
- elderly
Outdoor times and env
- route (parenteral > oral)
- higher SES
- summer and fall
- Hx of atopy
- Emotional stress
- Acute infection
- Physical exertion
- Hx of mastocytosis

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4
Q

Risk factors for increased anaphylaxis severity and mortality (3 categories, 8 total)

A

Extremes of age
- Very young
- Very old
Comorbid conditions
- CVS dz
- Pulm dz
Others
- Concurrent use of HTN meds
- Concurrent use of alcohol, drugs, sedatives, tranquilizers
- Recurrent anaphylaxis episodes
- Upright posture at time of onset of sx

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5
Q

ROSENS box

Etiologic agents causing anaphylaxis by immunologic mechanisms:

  1. IgE- Dependent (9)
  2. IgE- Independent (4)
  3. Direct Mast Cell (4)
A

IgE-Dependent
1. Food
2. Medications (abx, NSAIDs, immunologiques)
3. Insect bites
4. Latex
5. Hormones
6. Anesthetics
7. RCM
8. Occupational allergies (plant protein, animal protein)
9. Aeroallergies (pollen, dust)

IgE-Independent
1. RCM
2. NSAIDs
3. Dextrans
4. Biologic agents

Mast Cell:
1. Physical factors (exercise, cold, heat)
2. Ethanol
3. Meds like opioids
4. Idiopathic

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6
Q

3 Criteria for diagnosing anaphylaxis

A
  1. Hypotension + exposure to known allergen
  2. Skin finding AND one of:
    a. Hypotension
    b. Resp issue
  3. 2 or more of:
    a. Hypotension
    b. Resp
    c. GI
    d. Skin
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7
Q

Common anaphylaxis allergens ( 6)

A
  1. Food
  2. Insect bites
  3. Contrast
  4. Exercise induced
  5. Idiopathic
  6. Drugs
    • worse in obesity, male, old age
    • Common abx = Penicillin
    • Common med = NSAIDs
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8
Q

Anaphylaxis Epi dose:

  1. Adults
  2. Kids
A
  1. Epi 0.3-0.5mg of 1mg/mL IM
  2. Epi 0.01mg of 1:1000 IM

q5-10 min

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9
Q

Anaphylaxis resus (6):

A
  1. Epi
  2. Fluid resus
  3. Steroids (mb in pts w asthma)
  4. Diphenhydramine (in Rosens but not great)
  5. If 2 doses of Epi not helping –> pressors like norepinephrine)
  6. Glucagon mb helpful in patients receiving beta blockers
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10
Q

Who is at increased risk of biphasic anaphylaxis reaction? (7)

A
  1. Hypotension
  2. Wide pulse pressure
  3. Unknown triggers
  4. Prior anaphylaxis
  5. Delayed epi admin
  6. > 1 dose of epi received
  7. Cutaneous S&S
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11
Q

Dispo of anaphylaxis:

  1. If pt completely asymptomatic
  2. When for everyone else?
  3. When does most biphasic reactions occur?
A
  1. After 1 hour
  2. after 4-6 hour if sx completely resolved
  3. After 6 hours (97% of cases)
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12
Q

Angioedema with urticaria treatment

A

H1-antihistamines (Cetirizine, loratadine)

2nd line: Short course of oral steroids

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13
Q

Angioedema without urticaria treatment?

A

Mainly supportive

Manage airway if needed

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14
Q

tPA induced angioedema treatment?

A

Antihistamines and corticosteroids

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15
Q

DDX of anaphylaxis? (4 categories, > 20 in Rosen’s box page 1424..)

A

Common
1. Urticaria
2. AsthmaE
3. MI
4. PE
5. Syncope
6. Anxiety/Panic attack

Flush syndrome
7. Alcohol
8. Mastocytocis

Shock syndrom e
9. Septic shock
10-13. All the other shocks

Others:
14. Hypoglycemia
15. HAE
16. ACEi angioedema
17. Red man syndrome
18. Pheo

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16
Q

RFs for death from asthma (9)

A

Hospitalization
- Hx of Near fatal asthma requiring intubation
- Hospitalization or ED visit for asthma in past year
Meds
- Using oral steroids
- Not using inhaled steroids
- Overusing SABA
- Poor adherence to drugs
ETC
- Psychosocial problems
- Psych disease
- Food allergy in patient with asthma

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17
Q

Asthma exacerbation treatment in ED, puffers and steroids:
- which puffers, how much of each?
- how much steroids?

A

Beta agonist: MDI > nebulizer
SABA
Under 20kg - 4 puffs q15min
Over 20kg - 8 puffs q15
○ No role for LABA
SAMA
ie Iprotropium

Steroids
Prednisone 50mg or dexamethasone
Methylpred IV (125mg/day) also recommended for peds

*If systemic corticosteroids, discharge home with 5-7 days of prednisone 50mg/day0po

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18
Q

Role of Mg2+ in asthma exacerbation:
1. Effect on airways?
2. Dose in adults? Kids?

A
  1. Relaxes bronchial smooth muscles
    Dilates airways
  2. Adults: 2g IV over 20 minutes
    Kigs: 40mg/kg/day
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19
Q

What is the role of HeliOx in asthma exacerbation?

A

Mixing helium with O2 reduces the gas’ density (as compared to nitrogen in ORA) so helps with airflow, reduces resp muscle work, dec wOB
○ Especially when heliox was used with SABA through nebulizers

Consider when:
- Severe airflow obstruct
- Hx of labile asthma
- Previous intubation
- Inability to adequately mech vent

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20
Q

6 indications to intubate asthmatic patient?

A
  1. Coma
  2. Altered consciousness
  3. Cardiac/resp arrest
  4. Paradoxical breathing pattern
  5. Refractory hypoxemia
  6. Failure of NIV
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21
Q

Preferred agent of induction for RSI of asthmatic patients? why?

A

Ketamine - bronchidilatory effect

Propofol also good but watch out for hypotension

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22
Q
  1. Pediatric ABC triangle?
  2. Pneumonic “TICLS” for appearance?
A
  1. Appearance, WOB, Circulation
  2. Tone
    Interactiveness
    Consolability
    Look/Gaze
    Speech/Cry
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23
Q

Difference between resp distress VS resp failure in kids?

A

Resp distress - S&S of abnormal respiratory pattern, a clinical diagnosis

Resp failure - Inability of lungs to oxygenate or remove CO2, an objective diagnosis

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24
Q

5 clinical signs of resp failure in paediatrics?

A
  1. Grunting
  2. Decreased breath sounds
  3. “Normal” breathing but worsening clinically
  4. LOC change
  5. Color change
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25
Q

3 ABG Criteria for resp failure?
- PCO2 level
- PO2 level
- pH

A

PCO2 > 50 mmHg

PO2 < 60 mmHg

pH < 7.35

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26
Q

5 DDX of upper airway and 5 ddx of lower airway dz in paediatrics?

A

Upper Airway:
1. Croup
2. Epiglottis
3. FB
4. RPA
5. Tonsilitis

Lower Airway:
1. Asthma
2. Pneumonia
3. CF
4. Bronchiolitis
5. PE
6. Sickle cell crisis

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27
Q

5 ddx of non-pulmonary/non-cardiac causes of respiratory distress?

A
  1. Increased cerebral pressure
  2. Toxic encephalopathy
  3. DKA
  4. Lactic acidosis
  5. Toxic shock syndrome
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28
Q

Bronchiolitis:

  1. Most common virus? Other ones (2)?
  2. Best treatment?
  3. Five complications?
A
  1. RSV ; Rhinovirus, Influenza
  2. O2 support and Hydration! NO MEDS or PUFFERS or STEROIDS! No evidence
  3. Otitis Media
    Sepsis
    Apnea
    Resp failure
    Dehydration
29
Q

3 treatments with equivocal evidence for treating bronchiolitis?

A
  1. Epinephrine nebulization
  2. Combined epi and dex
  3. Nasal suctioning
30
Q

Bronchiolitis admission criteria? (6)

A
  1. Severe resp distress
  2. Supplemental O2 required
  3. Cyanosis/Apnea
  4. Dehydration/dec PO intake
  5. “high risk” infant
  6. Parents not coping
31
Q

RFs for admission of bronchiolitis? (4)

A
  1. < 12 weeks
  2. Prematurity < 35 weeks
  3. Immunodeficient
  4. Cardiopulm dz
32
Q

Bronchiolitis prophylaxis? Who gets it? (3)

A

Palivizumab -
Chronic lung dz
Congenital Heart dz
Premature

33
Q

What is the pathophys of CF?

A

Autosomal recessive mutation in CFTR gene - leading to defect in chloride transport and dec ciliary clearance, thickened mucus, bacteria adherence

34
Q

2 overarching features of CF?

A
  1. Pancreatic insufficiency
  2. Chronic infections
35
Q

Cystic Fibrosis:

  1. 5 Bacteria causing CF exacerbation? Which has the highest mortality?
  2. Treatment in ED?
  3. Abx choice?
A
  1. Staph aureus (+/-MRSA)
    Non-typeable H. influenza
    Sternotrophus Maltophilia
    Pseudomonas
    Burkholderia Cepacia (BAAAAD)
  2. Bronchodilators and N-Acetylsysteine puffers ; Chest physio ; Abx
  3. Beta-lactams & Aminoglycoside
  • Cover for pseudomonas bc 98% colonize it by the age of 3!!
36
Q

Sore throat red flags (3 categories)

A

Suspicion for deep neck space infection ie. truisms, severe pain, large mass

Toxic patient

Signs of impeding airway obstruction like drooling, stridor, tripping

37
Q

DDX stridor (10)

A

Choanal atresia
RPA
PTA
Adenotonsilar enlargement
Ludwig’s Angina
Neoplasm
FB
Trauma
Laryngomalacia
Croup
Epiglottis
Tracheitis
Laryngospasm

38
Q

Most common cause of congenital stridor?

A

Laryngomalacia

39
Q

Laryngomalacia:

  1. Pathophys?
  2. Stridor worsens when..? (4)
  3. What age does it come on? What age is it resolved?
  4. Dx? Treatment?
  5. Indications for surgery (4)
A
  1. Incomplete development of laryngeal cartilage –> epiglottis falls on it and causes stridor
  2. Prone, neck flexion, crying, feeding
  3. A few weeks after life ; resolves by 2 years
  4. Awake endoscopy ; usually self resolves
  5. Severe
    Feeding difficulty
    Apnea
    Cyanosis
40
Q

Croup:

  1. Age range?
  2. Viruses?
  3. Sx?
  4. When is it worse? (2)
  5. Treatment?
A
  1. 6 months - 6 years
  2. Parainfluenza virus (most common)
    Influenza A & B
    Rhinovirus
  3. Viral prodrome –> 12-48 hours later, Barky cough, hoarse voice, biphasic stridor

4.
With Crying
At night

  1. Dexomethasone 0.6 mg/kg

Aerosolized epinephrine - to those w stridor at rest & resp distress .. must be watched for 2-3 hours at rest to ensure no rebound

41
Q

Bacterial tracheitis:

  1. What is it?
  2. Most common bacteria?
  3. Diagnosis?
  4. XR finding?
  5. Treatment?
A
  1. Superinfection/ complication of croup!
    *Most common cause of resp failure from infectious stridor (especially since the HIB vaccine and steroids for croups have been used)
  2. Staph aureus /MRSA .. but others can cause it too
  3. Clinical! Confirm with direct laryngoscope
  4. STEEPLE SIGN! “Shaggy” trachea
  5. Abx (Cftx + Vanco) +/- endoscopic debridement
42
Q

Classic triad of FB aspiration?

A
  1. Cough
  2. Wheeze
  3. Decreased unilateral breath sound

*This is v rare

43
Q

Foreign body gold standard for treatment?

A

Bronchoscopy

*also good for treatment

44
Q

Epiglottitis

  1. What is it?
  2. Bacteria?
  3. Diagnosis?
A
  1. Invasive bacteria infl of epiglottis
  2. H influenza B (historically)
    H influenza A
    Streptococcus
    Staph aureus

3.
Lateral neck xray

  1. Airway management!!!
    IV abx etc.
45
Q

Adult epiglottis

  1. Causes
  2. RFs
  3. S&S
  4. Dx
  5. Tx
A
  1. S. pneumo
    S. Pyogen
    S. Aureus

2.
Infection
Thermal burn
Trauma
Cocaine

  1. Smoking
    Drugs
    HTN
    DM
    ESRD
    IC
  2. Toxic appearance
    Stridor
    Drooling
    Resp distress
    + pharyngitis, dysphagia etc
  3. Direct visualization
    Lateral neck XR and CT also

6.
Cftx + Vanco
+ Nebulized epi + systemic steroids + bronchodilators + consider intubation

46
Q

Epiglottitis neck XR findings? (5)

A
  1. “Thumbprint sign” - enlarged epiglottis
  2. Lack of air in vallecula
  3. Thickened aryepiglottic folds
  4. Distended hypopharynx
  5. Straightened C spine

*Only 30-60% abnormal!

47
Q

PeriTonsillar Abscess

  1. Pathogens
  2. RFs/causes (7)
  3. Investigation
  4. Tx (6)
A
  1. Polymicrobial
    Fusobacterium Necrophorum
  2. Tonsilitis
    GAS
    Pharyngitis
    Mono
    Tonsil stones
    Dental procedures
    Smoking
  3. Monospot
  4. I&D
    Abx Cftx + Flagyl
    Analgesia
    Dex
    Observe to ensure no complications
    Outpatient FU
48
Q

RetroPharyngeal Abscess

  1. Causes (10)
  2. Dx: Gold standard + alternatives
  3. Tx
A

1 .
Pharyngitis
Tonsillitis
PTA
AOM
Dental infections
FB
Trauma
Ludwig Angina
Oral procedures
Endoscopy

  1. CT gold standard
    XR and US also able
  2. Tazo + Vanco (polymicrobial)
    Airway management!
    ICU/ENT dispo
49
Q

Diphtheria

A

Diphtariae

URI, fever, malaise, Greyish membrane on palatines

Dx with culture

Tx with Diphtheria antitoxin, PenG

50
Q

Mono

  1. Pathogen
  2. Dx
  3. Tx
  4. Who gets steroids?
A
  1. EBV
  2. Monospot most sensitive
  3. Supportive
  4. If sever complications ie. airway obstruction, liver failure, hemolytic anemia
51
Q

Most common source of bleeding in minor hemoptysis? Major hemoptysis?

A

Minor = tracheobronchial capillaries

Major = bronchial arteries

52
Q

10 causes of hemoptysis (VINDICATE)

Most common?

A

V - AV malformation
I - Infection (TB, pneumonia)
N - Neoplasm
D - Drugs (cocaine)
I - Iatrogenic
C - Congenital
A - Lupus, vasculitis, bronchitis
T - Trauma
E - Environmental

*Most common = neoplasm

53
Q

Diffuse alveolar hemorrhage

  1. What is it?
  2. Causes
A
  1. Bleeding into alveolar space due to capillaries or vessels rupturing
  2. Infection, vasculitis, SLE, cocaine
54
Q

Hereditary Hemorrhagic Talengectiasia:

  1. What is it?
  2. Most common areas?
  3. What is the biggest concerns?
  4. What can they not do? (3)
A
  1. Inherited disorder that causes arteriovenous malformations (AVMs), to develop between arteries and veins.
  2. Nose, lungs, brain and liver
  3. air emboli that can travel to brain!!
  4. Scuba dive, prophylactic abx before procedures, not take NSAIDs!
55
Q

2 definitions of massive hemoptysis

A
  1. > 100mLs of blood loss in 24 hours
  2. Any hemop that causes hemodynamic instability OR causes resp distress
56
Q

Intubation of massive hemoptysis:

A
  1. Consider awake intubation to preserve cough
  2. Consider right main bronchus ETT with Fogarthy catheter to pass by to left side to tamponade
  3. Advanced intubation with double lumen
57
Q

Causes of early tracheal bleed (3)

Causes of late treach bleed (3)

A

Early:
- Manipulation of tube
- Bleeding at surgical site
- Operative injury to vessel

Late:
- Infection
- Granulation tissue
- Trachoinominnate fistula

58
Q

Tracheoinnominate fistula bleed: what do you do?

A

Call for help, ABCs

Overinflated the cuff –> intubate from above –> remove trach –> digital compression of the innominate artery

59
Q

GOLD definition of COPD

A

A common, preventable and treatable disease that is characterized by persistent respiratory symptoms and airflow limitation that is due to airway or alveolar abnormalities usually caused by significant exposure to noxious particles or gases.

60
Q

COPD RFS (6)

A
  • Cigarette smoking BIGGEST RF
  • Male
  • Age > 40
  • Indoor pollution
  • Occupational exposures
  • Genetic alpha-1 antitrypsin deficiency
61
Q

GOLD criteria COPD severity

A

Mild = FEV1 > 80%
Moderate = 50 - 80%
Severe = 30 - 80%
Very severe = < 30%

62
Q

ROSENS BOX: Classification of resp failure in COPD

  • No resp failure (5)
  • Acute resp failure (5)
  • Severe failure (3)
A

No resp failure
- WOB: normal
- tachypnea: mild, 20-30
- Hypoxemia: mild, responsive to nasal canula
- Hypercapnia: none
- Baseline mental status

Acute resp failure
- WOB: increased with accessory muscle use
- tachypnea: sig, >30
- Hypoxemia: responsive to FiO2 < 35%
- Hypercapnia: 50-60 & pH > 7.25
- Baseline mental status

Severe:
- Hypoxemia FiO2 > 35%
- PaCO2 > 60% or pH < 7.25
- AMS

63
Q

Causes of COPD exacerbation

A
  1. Bacterial: S. pneumo, H.influenzae, Pseudomonas
  2. Viral: RSV, Rhinovirus, Influenza
  3. Environmental
  4. Med non-compliance
64
Q

COPD patient ECG?

A
  1. P pulmonae (Peaked t waves, low QRS voltage, poor R wave progression from precordial leads)
  2. Dysrhythmia
  3. RVH
65
Q

COPDE management in ED

A
  • SABA and SAMA back to back
  • Corcicosteroids
  • NIPV
66
Q

Exclusion criteria for NIV ( 8)

A
  1. Resp arrest
  2. CVS instability
  3. Upper airway obstruction
  4. Aspiration risk
  5. Aggitated patient
  6. Craniofacial trauma
  7. Recent facial surgery
  8. Non fitting mask
67
Q

COPD GOLD criteria for admission (6)

A
  1. Sig worsening sx
  2. Bad response to ED tx
  3. Sig comorbidities
  4. Worsening hypoxia, inc CO2
  5. Failed outpatient management
  6. Social situation bad
68
Q

COPD, BiPAP:

  1. Indications (3)
  2. Contradictions (4)
A

Indications:
- Resp acidosis Co2>45 & pH < 7.35
- Severe days
- Persistant hypoxemia dispute supplamental O2

Contradictions:
- Active vomiting/high risk aspiration
- Resp arrest
- Facial trauma
- Depressed mental status

69
Q

COPD, intubation:

  1. Indications (7)
  2. Contradictions (2)
A

Indications:
- Not tolerating NIV
- NIV failure
- diminished consciousness
- Resp/cardiac arrest
- Not removing secretions
- Hemodynamic inst w/o respond to fluids
- Hypoxemia not corrected by NIV

Contraindications
- Appropriate for NIV
- DNR/DNI

Rosen's (3 decks)

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