ED 2 Respiratory

Question 1

current steroid use or recent withdrawal from oral steroids puts you at risk for what?

Answer 1

asthma exacerbation

Question 2

what is a MAJOR risk factor for death in an asthmatic who’s having an exacerbation?

Answer 2

prior intubations, ICU admissions, exacerbations

Question 3

what are more mild risk factors for death in an asthmatic who’s having an exacerbation?

Answer 3

use of 2 or more albuterol inhalers in past month

use of air conditioning

Question 4

at what levels of the following are considered a warning sign in an asthma exacerbation?

1) peak flow
2) PAO2
3) PCO2
4) pulsus paradoxus

Answer 4

1) peak flow less than 100-80
2) PAO2 less than 60 mmHG
3) PCO2 greater than 45 mmHG
4) pulsus paradoxus greater than 20 mmHG

Question 5

what are the three medications often given during asthma exacerbation?

Answer 5

1) albuterol by nebulizer (beta-2 agonist)
2) steroids PO or IV (equal in time of onset)
3) epinephrine IM

Question 6

what medication is the standard and MUST be on board in severe asthma exacerbations?

Answer 6

epinephrine

Question 7

do inhaled corticosteroids play a large role in acute asthma exacerbation?

Answer 7

NO

Question 8

which medication can be used as an alternative to epinephrine in the case of heart disease?

Answer 8

terbutaline
selective beta2 agonist
less cardiac SE but expensive!

Question 9

which medication can be used during acute asthma exacerbation, which is safe in pregnancy with very little downside?

Answer 9

magnesium sulfate

Question 10

which gas is 25 percent as dense as room air is is sometimes used as a nebulizer treatment in acute asthma exacerbation?

Answer 10

helium

set it to rate of 8-10 L/min

Question 11

a silent chest should make you concerned for what?

Answer 11

status asthmaticus

Question 12

which acid base disorder will a patient in status asthmaticus have?

Answer 12

severe respiratory acidosis

Question 13

how do we manage status asthmaticus?

Answer 13

may have to intubate; do not delay once deemed necessary

Question 14

what do you do if your patient in an asthma exacerbation is pregnant?

Answer 14

do EVERYTHING the same

Question 15

thin, barrel chest, clubbing of fingers, pursed lips, prolonged expiratory phase are all signs of what?

Answer 15

COPD patient

Question 16

what are the three tiers of managing COPD exacerbations?

Answer 16

1) medication therapy and supplemental O2
2) positive pressure ventilation
3) intubation

Question 17

what 3 treatments are given to a patient in moderate-severe COPD exacerbation?

Answer 17

1) ipratroprium bronchidilator by nebulizer or MDI
2) corticosteroids (for all but mild exacerbations) - either prednisone PO for 7-14 days or methylprednisone IV for 7-14 days
3) NIPPV (bipap or cpap)

Question 18

why do we prefer NIPPV to intubation in our COPD patient?

Answer 18

less invasive
decrease need for intubation
reduce hospital stay
reduce mortality

Question 19

you can ONLY do NIPPV when a patient is capable of what?

Answer 19

breathing on their own

Question 20

you should intubate and mechanically ventilate a COPD exacerbation patient should any of these three criteria occur

Answer 20

1) change in mental status
2) increased distress with cyanosis
3) acute deterioration/exhaustion

do everything you can to avoid!

Question 21

your patient with a COPD exacerbation began producing increased sputum and fever, you decide to RX ABX. what are you going to give?

Answer 21

macrolides or fluoroquinolones outpatient

Question 22

what is hypercarbia? what does it lead to?

Answer 22

CO2 retention seen in COPD

leads to respiratory acidosis, hyperventilation

Question 23

why must you be sure to not give too much O2 to your patient with a COPD exacerbation?

Answer 23

can lead to respiratory arrest/depression secondary to loss of hypoxemia-induced ventilatory drive

Question 24

your young, non-smoking patient presents with emphysema. what should you work up?

Answer 24

alpha1-antitrypsin deficiency syndrome

leads to increased protease tissue destruction (bc alpha1-antitrypsin usually protects lungs from destruction) and emphysema in younger people

Question 25

what is the mortality rate of untreated pneumonia in a normal host?

Answer 25

30 percent

Question 26

which three populations of people typically have atypical presentations of pneumonia?

Answer 26

1) elderly
2) alcoholics
3) immune compromised

Question 27

if your patient with pneumonia requires admission, what are the ABX of choice?

Answer 27

fluoroquinolones

Question 28

according to lecture this time around, what is the classic triad of PE?

Answer 28

pleuritic chest pain, dyspnea (MC), hemoptysis

Question 29

what must you do before ordering any labs or imaging for your workup for PE?

Answer 29

determine pre-test probability with a well’s score or PERC rule for PE

Question 30

who is most at risk for spontaneous pneumothorax?

Answer 30

tall thin man smokers

Question 31

how will a patient with spontaneous pneumothorax present?

Answer 31

ABRUPT pleuritic chest pain with dyspnea

often tachycardic, tachypneic

Question 32

when you auscultate a patient with spontaneous pneumothorax, what will you note?

Answer 32

decreased breath sounds

Question 33

how will you manage the following pneumothorax patients?

1) mild
2) urgent
3) emergent

Answer 33

1) mild = do nothing, repeat x-ray in 24 hours
2) chest tube if urgent
3) needle decompression if emergent

get a thoracic referral!

Question 34

how does one develop a traumatic pneumothorax? what do we worry most about?

Answer 34

blunt or penetrating trauma

worry about tension pneumothorax

Question 35

you get a chest x-ray of your patient with traumatic pneumothorax and note a fluid line, whats up?

Answer 35

hemopneumothorax

Question 36

what will you note on auscultation of your patient with a traumatic pneumothroax?

Answer 36

hyperresonance
tympany
subcutaneous emphysema (snap, crackle, pop)

Question 37

how do we treat traumatic pneumothorax?

Answer 37

emergent needle decompression; mid-clavicle 2nd intercostal space

chest tube placement to drain blood