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Emergency Medicine > Dyspnea > Flashcards

Dyspnea Flashcards

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1
Q

MC precipitating factors of AHF

A
  • Afib
  • AMI
  • DC of meds (diuretics)
  • Increased Na load
  • Meds impairing myocardial function
  • Physical overexertion
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2
Q
  • DOE, dyspnea, frothy pink sputum, rsp distress
  • Tachycardic, HTN, S3
  • Abdominojugular reflux and JVD

dx?
mgmt?

A
  1. AHF
  2. O2 >95% (CPAP/BiPAP), NTG, nitroprusside, diuretics, morphine
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3
Q

6 AHF classifications

A
  1. HTN AHF
  2. Pulm edema
  3. Cardiogenic shock
  4. Acute-on-chronic
  5. High-output failure
  6. RHF
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4
Q
  • Preserved LV function
  • SBP >140
  • CXR: pulm edema
  • Onset < 48h

which type of AHF

A

HTN AHF

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5
Q
  • Rsp distress
  • Rales
  • Low O2
  • CXR

which type of AHF

A

pulmonary edema

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5
Q

Tissue hypoperfusion
SBP <90

which type of AHF

A

Cardiogenic shock

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5
Q
  • Mild-moderate s/s
  • Do not meet criteria for others
  • SBP 90-140
  • Increased peripheral edema
  • Onset: several days

which type of AHF

A

Acute-on-chronic

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6
Q
  • High CO
  • Tachycardia
  • Warm extremities
  • Pulm congestion

which type of AHF

A

High-output failure

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7
Q

Most important hx parameter for AHF

A
  • h/o AHF
  • DOE (84%)
  • Paroxysmal nocturnal dyspnea, orthopnea, edema (77-84%)
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8
Q

w/u for AHF?
findings?

A
  • ECHO!
  • CXR: pulm venous congestion, cardiomegaly, interstitial edema; nml possible
  • ECG: not helpful
  • BNP: helpful if dx uncertain
  • Cardiac US: determines other causes for acute dyspnea, LV function and volume status or find signs of pulmonary congestion
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9
Q

mgmt for HTN AHF with severe HTN - Pulmonary edema with SBP 150

A
  1. Vasodilators
  2. Avoid need for emergent intubation
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10
Q

AHF - HoTN persist after NTG, next step?

A

IV fluid bolus 250-1000cc
RV infarction, valvular pathology (AS, hypovolemia, ED meds)

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11
Q

High-Risk AHF Pts that require admission

A
  1. AMS
  2. Persistent hypoxia
  3. HoTN
  4. Elevated trops
  5. Ischemic ECG changes
  6. BUN >43
  7. Cr >2.75
  8. Tachypnea
  9. Inadequate UO
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12
Q
  • asx to sudden death
  • **Acute dyspnea **
  • Pleuritic CP
  • Unexplained tachycardia
  • Hypoxemia
  • Syncope
  • Shock; seizures possible - esp no PE/imaging findings for other DDx
  • hypoxemia, tachypnea, tachycardia, hemoptysis, diaphoresis, low-grade fever
  • DVT in 50% of pts

dx?

A

PE

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13
Q

w/u for PE

A
  1. Pretest probability - for probability of disease >2.5%
    - low-risk = PERC
    - need more testing = Wells
  2. Need additional testing + low/intermediate pretest → D-Dimer
  3. High pretest/(+) D-Dimer → imaging - CTPA; VQ scan
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14
Q

Other causes of elevated D-Dimer

A
  1. older
  2. pregnant
  3. active malignancy
  4. recent surgery
  5. liver dz
  6. rheumatologic dz
  7. infection
  8. trauma
  9. sickle cell
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15
Q

mgmt for PE

A
  1. O2
  2. IV crystolloid fluids
  3. UFH / LMWH / rivaroxaban / apixaban / fondaparinux ASAP
  4. fibrinolytic (if severe PE causing SBP < 90 / decr BP of 40 mmHg)
    - add Heparin/LMWH afterwards
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16
Q

mgmt if Life-threatening PE + CI to fibrinolysis?

A

Surgical & suction thromboembolectomy
High mortality with open surgical thromboembolectomy

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17
Q

PE - mgmt if Failed/CI anticoag; associated DVT

A

IVC filter

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18
Q

disposition of PE

A
  • Admit to telemetry
  • ICU: circulatory compromise; when thrombolytics given and close monitoring is needed
  • some low-risk pts can do outpatient tx
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19
Q

MCC of bronchitis

A
  1. Influenza A/B, adenovirus, rhinovirus, parainfluenza, RSV, COVID
  2. Uncommon: S. pneumo, H. flu, C. pneumo, M. pneumo, pertussis
    - More severe in older pts esp with comorbidities
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20
Q
  • Productive cough; Lasts 3 wks
  • Wheezing possible
  • Sputum alone does NOT indicate bacterial etiology
  • No fever, tachycardia, tachypnea

dx?

A

bronchitis

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21
Q

bronchitis criteria

A
  1. Acute-onset cough (< 3wk)
  2. No chronic lung dz hx
  3. Normal VS
  4. No auscultatory abnormalities that suggest pneumonia.
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22
Q

Consider ? in adolescents and young adults whose coughs >2-3 wks, esp if coughing paroxysms with prominent post-tussive emesis or had exposure

A

pertussis

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23
Q

w/u for bronchitis

A

Pulse ox indicated if dyspnea or appears SOB Bedside peak flow testing: reduced FEV1
CXR not required in nontoxic non-elderly pts

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24
Q

mgmt bronchitis

A
  1. No abx
  2. Pertussis: azithromycin PO - decr coughing paroxysms, limits transmission, does NOT shorten illness
  3. Airflow obstruction: albuterol
  4. Additional agents based on pt

DC for timely f/u with PCP, stop smoking

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25
Q

MCC PNA

A

MC bacterial infection - S. pneumo

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26
Q

RF for PNA

A

rsp tract dz, immunocomp, chronic conditions assoc w/ aspiration, bacteremia, debilitation

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27
Q

s/s of PNA

A
  • cough, fatigue, F, dyspnea, sputum, and pleuritic CP
  • Tachypnea, tachycardia, low pulse ox, bronchial BS, rhonchi or wheezing
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28
Q

criteria for HCAP

A

hospitalized >48h within 90 d, routine outpatient dialysis, chemo, wound care, or home IV abx, and residents of a nursing facility

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29
Q

Aspiration PNA MC happens in what part of the lung

A
  • RLL d/t gravity and lung anatomy
  • Can happen anywhere in the lung
  • Complications: empyema, lung abscess
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30
Q

w/u for PNA

A
  • Uncomplicated, healthy - no w/u
  • CXR MC
  • CBC, BMP, ABG, sputum gram staining & cx, blood cx - better if being admitted to ICU
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31
Q

mgmt for outpatient, uncomplicated CAP

A
  1. Amoxil or doxy PO >5d
  2. macrolide if failed
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32
Q

mgmt for Outpatient, comorbidities CAP

A
  1. augmentin + macrolide/doxy
  2. FQ
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33
Q

mgmt for Inpatient not ICU CAP

A
  1. Rocephin + macrolide
  2. FQ
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34
Q

mgmt for ICU CAP

A
  1. rocephin + FQ
  2. MRSA: add vanc
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35
Q

mgmt for inpatient HCAP

A
  1. Levo + cefepime OR pip/taz
  2. Add vanc/linezolid for MRSA
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36
Q

mgmt for aspiration PNA

A
  1. Prophylactic abx not recommended
  2. Witnessed aspirations - Tracheal suction, then bronchoscopy if need to remove large particles
  3. PNA: levo + clinda
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37
Q

mgmt of empyema in PNA

A
  • Pip/taz; Admit, consult pulm/thoracic surgeon
  • Add vanc for MRSA
38
Q

mgmt for lung abscess from PNA

A

Clinda + rocephin

39
Q

MC RF for spontaneous pneumothorax

A

smoking

40
Q

difference between primary vs secondary pneumothroax

A
  • Primary: w/o known lung dz
  • Secondary: w/ known lung dz (COPD, asthma, CF, ILD, infection, CTD, cancer)
41
Q

pneumothorax that occurs secondary to invasive procedures (needle lung bx, thoracentesis, subclavian line, NG tube, PPV)

dx?
what can be done to reduce this complication?

A
  • Iatrogenic
  • US guidance for central venous catheter insertion for thoracentesis
42
Q

s/s pneumothorax

A
  • MC Sudden onset of dyspnea, ipsilateral pleuritic CP
  • Tachycardia MC PE
  • Spontaneous: classic PE findings not common
  • Traumatic: ipsilateral decreased BS
43
Q

s/s tension pneumothorax

A
  • severe progressive dyspnea, tachycardia (>140), hypoxia, ipsilateral decreased BS;
  • Late findings: tracheal deviation AWAY from affected side, distended neck veins, cardiac apical displacement
    *
44
Q

w/u for pneumothorax?
findings?

A
  1. Stable → PA CXR: Displaced pleural line w/ absent lung markings extending from visceral pleura to chest wall
  2. Supine AP XR: cardiophrenic recess hyperlucency and CPA enlargement (deep sulcus sign)
  3. CT → r/o emphysematous bullae
  4. Young, healthy → US: no lung sliding, comet tail artifacts and a lung pulse in presence of a distinct A lines and visualized lung point.
  5. Iatrogenic pneumothorax - CXR after central line placement or transthoracic needle procedures
    - May not identify pneumothorax if supine or if there is inadequate time for pneumothorax to develop
45
Q

mgmt for small primary pneumothorax

A

observe x 4h on O2, repeat CXR

  1. No sx and nml CXR: return in 24h for repeat exam, then wkly until resolution
  2. 1st time spontaneous of < 20% lung volume in a stable, healthy adult: O2 and observe
46
Q

Locations for needle aspiration or tube throacostomy for pneumothorax

A
  1. anteriorly in 2nd ICS at MCL
  2. laterally in 4th/5th ICS at AAL - 5th preferred for needle thoracostomy decompression
47
Q

indications for chest tube thoracostomy

A
  1. failed aspiration
  2. large pneumothorax
  3. Recurrent pneumothorax
  4. bilateral pneumothoraces
  5. Hemothorax
  6. abnormal VS
  7. severe dyspnea
48
Q

mgmt for tension pneumothorax

A

Needle decompression then tube thoracostomy ASAP

49
Q

re-expansion lung injury from pneumothorax is MC seen when?
mgmt?

A
  • if lung collapse >72h, large pneumothoraces, rapid re-expansion, or negative pleural pressure suction >20 cm
  • observation, O2 supp
50
Q

triggers for asthma and COPD

A

smoking, respiratory infections, exposure to noxious stimuli, adverse response to meds, allergic reactions, hormonal changes during the normal menstrual cycle or pregnancy, and noncompliance with prescribed therapies

51
Q

asthma exacerbations are due to?

A

expiratory airflow limitations

52
Q

COPD exacerbations are due to?

A

vent-perfusion mismatch

53
Q

2 forms of COPD? differences?

A
  1. pulmonary emphysema: defined in anatomic pathology, characterized by destruction of bronchioles and alveoli
  2. chronic bronchitis: defined in clinical terms as a condition of excess mucous secretion in bronchial tree, with a chronic productive cough for 3 mo in each of 2 consecutive yrs
54
Q

MC chronic disease of childhood

S/S:
- Dyspnea, chest tightness, cough
- Wheezing w/ prolonged expiration

dx?

A

asthma

55
Q

w/u for asthma

A
  • DX: clinically
  • FEV1 and peak expiratory flow rate (PEFR) - FEV1/PEFR < 40% = severe
  • ABG - if hypercapnia and acidosis in severe cases
  • CXR if indicated: Complicating cardiopulm process suspected (temp >38.3, unexplained CP, leukocytosis, hypoxemia)
  • pt requires hospitalization
  • unknown dx
  • EKG
56
Q

general mgmt for asthma and COPD

A
  1. keep SpO2 >90% or PaO2 60-70mmHg
  2. 1st line: SABA: Albuterol neb
    - Severe (FEV1/PEFR < 40%): +Ipratropium bromide (DuoNeb)
    - Terbutaline/EPI if cannot tolerate aerosols
  3. Prednisone for exacerbations
    - Methylprednisolone if cannot tolerate PO
57
Q
  • If rsp muscle fatigue, rsp acidosis, AMS, or hypoxia refractory to standard therapies.
  • alt to intubation and invasive vent
A

NPPV: CPAP / BiPAP

BiPAP has pro of reducing work of breathing

58
Q

When NPPV not viable, what is the next step?

A

oral intubation

  • Therapy guided by pulse ox, capnography, and ABG results.
  • Continue sedation and therapy for bronchospasm
  • Mech vent itself does not relieve airflow obstruction
59
Q

↑ in:
- frequency/severity of cough
- volume or change in sputum
- dyspnea

  • Mild: increased regular meds
  • Moderate: Requires systemic corticosteroids or ABX
  • Severe: Requires ER evaluation

dx?

A

COPD Exacerbation

60
Q

mgmt for severe asthma exacerbation ONLY (FEV1 < 25% predicted)?
refractory asthma?

A
  1. Magnesium sulfate or 80%:20% Heliox
  2. Ketamine
61
Q

COPD exacerbations receive ABX if 2 out of 3 findings:
what are the abx?

A
  • ↑ dyspnea, ↑ sputum volume or purulence
  • Macrolide, Bactrim, 3rd gen cephalo
  • Augmentin or FQ if high-risk if: >65yo, comorbidities, continuous supplemental O2, hospitalization in last 12 months exacerbation, COPD exacerbation, FEV1 < 50%
62
Q

when is Stridor heard?

A
  • upper airway obstruction
  • Forced air through large airways
  • High pitch inspiration
63
Q

Accessory muscle use:

A

SCM, sternoclavicular, intercostal

64
Q

what is paradoxical abdominal wall movement

A

the abdominal wall retracts inward with inspiration, indicating diaphragmatic fatigue

65
Q

depressed consciousness is d/t?

A

hypercapnia

66
Q

what dyspnea imaging
helps differentiate acute cardiac from noncardiac causes
pleural effusion, pneumothorax, pulmonary consolidation, intravascular volume status, cardiac tamponade, cardiac function

A

Bedside Point of Care Ultrasound

67
Q

low flow vs high flow O2?

A
  1. Low flow oxygen (allows room air to mix with oxygen)
    - NC (0.25-4 lpm)
    - Simple mask (6-10 lpm)
  2. High flow oxygen (pure oxygen)
    - NC (4-40 lpm) - provide some positive pressure and decreases amount of room air that is breathed in
    - Non-rebreather (10-15 lpm)
68
Q

mgmt goal of hypoxia

A
  1. keep PaO2 >60 mmHg or O2 >90%
    - Lower oxygen goals in patients chronic lung disease (CO2 retainers) - risk of rsp depression in chronically hypercapnic
69
Q

MC cause of stridor in neonates due to a weak larynx

A

Laryngotracheomalacia

70
Q

Consider what dx in ALL children who present w/ respiratory complaints

A

Airway Foreign Body

MC: 1-3 years old

71
Q

MC objects and foods for airway FB

A
  • MC Object: Food & toys
  • MC Foods: Peanuts, sunflower seeds, carrots, raisins, grapes, hot dogs
72
Q

s/s of airway FB

A
  • sudden coughing/choking associated with gagging, stridor or cyanosis
  • Laryngotracheal FB - stridor, hoarseness or complete apnea
  • Bronchial FB (MC) - unilateral wheezing and decr breath sounds
73
Q

w/u for airway FB

A

Imaging: May be normal, do not delay intervention

  • Tracheal FB: PA & lateral soft tissue neck
  • Bronchial FB: PA & lateral CXR - Inspiratory & expiratory: Air trapping
74
Q
  • XR shows circular object on AP/PA view, where is the coin FB?
  • what if it presented as circular on lateral view?
A
  • esophagus
  • trachea
75
Q

Evidence of radiolucent FB may present with:

A
  1. Unilateral obstructive emphysema
    - D/t FB obstructing expiration→ air trapping & mediastinal shift to opposite side
  2. Focal atelectasis w/ complete obstruction
  3. Consolidation→ scarring
76
Q

what airway FB intervention confirms or rules out dx, and is therapeutic to remove FB

A

Bronchoscope

77
Q

mgmt for complete airway obstruction from FB

A
  1. BLS
  2. direct laryngoscopy with FB extraction (if BLS fails)
  3. orotracheal intubation with dislodgment of FB more distally (if laryngoscopy fails)
  4. If ET intubation fails - needle cricothyroidotomy or emergency tracheostomy
  5. Consult pulm for emergent bronchoscopy if BLS and laryngoscopy fail
78
Q

mgmt for Partial airway obstruction

A

Bronchoscopy under general anesthesia

79
Q

Prodrome: cough coryza and mild fever
inspiratory stridor,“barking” “seal-like” cough, hoarseness, respiratory distress, fever

dx?

A

Croup (laryngotracheobronchitis)

80
Q

difference between mild/moderate/severe Croup?

A
  • mild: no stridor at rest
  • moderate: stridor at rest and mild retractions
  • severe: stridor at rest and severe retractions, anxious or agitated appearing, pale/fatigued
81
Q

soft tissue neck x-ray shows subglottic haziness, narrowing of the superior trachea “steeple sign” with normal epiglottis

dx?

A

Croup (laryngotracheobronchitis)

82
Q

T/F: Imaging (soft tissue neck x-ray) is
not necessary to make diagnosis if classic presentation

A

T

83
Q

standard care for croup

A

minimal disturbance, pulse ox monitor, antipyretics

84
Q

mgmt for mild croup

A

Outpatient, single dose of oral dexamethasone
IM dexamethasone or nebulized budesonide if unable to tolerate oral therapy

85
Q

mgmt for morderate - severe croup

A
  1. single dose dexamethasone, NEB (racemic) EPI, humidified oxygen
    - Heliox - 70-80% helium and oxygen 20-30% - used as a last resort before intubation
    - Intubation if no response to pharmacotherapy
86
Q

Discharge criteria for croup (6)

A

(must meet all)

  1. nontoxic
  2. no signs of dehydration
  3. O2 sat > 90% on RA
  4. reliable caregiver
  5. observation with improvement for 3 hours after last epi tx
  6. f/u in 24-48 hours with PCP
87
Q

Indications for admission for croup

A

(only needs to meet one)

  1. persistent stridor at rest
  2. persistent tachypnea
  3. persistent retractions
  4. persistent hypoxia
  5. > 2 doses of nebulized epi are needed
88
Q

Like croup, but more severe rsp distress & toxic appearing
- Thick mucopurulent secretions→ Upper Airway obstruction
- “Sore Throat” referring to trachea w/ tenderness to palpation

dx?
w/u?
mgmt?

A
  1. Bacterial Tracheitis
  2. Imaging not necessary; Bronchoscopy (after airway is secured)
    - confirms edema of trachea
    - therapeutic removal of thick mucopurulent tracheal secretions
    - C&S of secretions to help guide therapy
  3. Intubation and mech vent; Vanc + Unasyn/Rocephin; Consult pulm
    - Alt: FQ (levaquin or cipro) substituted for BL if allergy is present
89
Q

how long do kidneys take to compensate?

A

Compensation occurs with in 12-24 hours

90
Q

how long do lungs take to compensate?

A

Compensation can occur with in minutes

91
Q

What is assessed in an ABG?

A
  • pH
  • PaCO2 - assesses rsp component of acid/base regulation
  • PaO2 - the amount of O2 dissolved in serum
  • HCO3 - assesses the metabolic component of the acid/base regulation
  • O2Sat - oxygen saturation of hgb
92
Q

causes of Respiratory Acidosis?
mgmt?

A
  • alveolar hypoventilation
  • Acute causes: head trauma, chest trauma, lung disease, or excess sedation
  • Chronic causes: obesity, COPD, sleep apnea
  • tx: increase minute ventilation, bronchodilators with small amounts of O2, invasive ventilation assistance
93
Q

causes of Respiratory Alkalosis?
mgmt?

A
  • Alveolar hyperventilation - decr in CO2 = decr H+ = imbalance of cations and anions. The negatively charged proteins bind Ca++ = ionized hypocalcemia.
  • Etiologies: CNS tumors or stroke, infections, pregnancy, hypoxia, and toxins (e.g., salicylates), anxiety, pain, and iatrogenic overventilation of patients on mechanical ventilators
  • treatment of underlying condition

Emergency Medicine (20 decks)

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