L2: Airway Emergencies Flashcards
Assess every patient that comes in for signs of airway compromise:
appearance hypoxemia hypercarbia respiratory exhaustion use of accessory muscles retractions
How long does it take for brain damage to occur in respiratory arrest?
4 minutes at 21% O2 (room air)
Most common cause of airway obstruction
The patient’s tongue
Types of Airways
oral nasal laryngeal mask airway endotracheal intubation tracheostomy
Rule of thumb for invasive airway management
The most advanced practitioner should do it
Can you see an aspirated foreign body on xray?
No
Foreign body aspiration presentation
persistent cough
unilateral wheezing
no URI sx
decreased breath sounds
2 complications of foreign body aspiration
postobstructive atelectasis
pneumonia
Le Fort I fracture
horizontal across maxilla
Le Fort II fracture
pyramidal, disrupts inferior orbital rim
Le Fort III fracture
transverse
Which kind of facial trauma can’t get nasal airways? Why?
Le Fort I and III fractures
Possible cribriform plate fractures, tube could end up in brain
What’s important about airways in burn patients?
Even if they look okay, they might have massive swelling later that obstructs airway
MUST intubate ASAP to secure airway
Common anaphylaxis triggers
abx ASA NSAIDs shellfish nuts milk eggs grass hymenoptera (bee) stings
Anaphylaxis presentation
Angioedema Tightening in throat, chest Laryngeal swelling Bronchial spasm Hoarseness Stridor, wheezing Respiratory distress Apnea
Anaphylaxis physiology
Hypersensitivity, release of immune mediators→ antigen-IgE-antibody binds to mast cells→ histamine→ increased vascular permeability, vasodilation, bronchial constriction, increased mucous gland secretion→ Respiratory compromise, CV collapse
Important in initial assessment of anaphylaxis
Immediately check lungs
Tx of anaphylaxis
Airway management, O2
Antihistamines:
H1: diphenhydramine, hydroxyzine
H2: cimetidine
Beta-2 agonists: albuterol
Steroids: methylprednisolone (slow)
Endotracheal intubation/surgical airway
Diphenhydramine
H1 antihistamine
Hydroxyzine
H1 antihistamine
Cimetidine
H2 antihistamine
If a patient is anaphylactic and severely hypotensive
Epi: .3-.5 mg
→ IV: 1:10,000
→ SC: 1:1,000 (.1-.3 mg/kg)
IV bolus
Causes of angioedema
autosomal dominant insufficiency of C1-esterase inhibitor (rare)
ACE inhibitors (acquired, prevent breakdown of bradykinin)
Angioedema treatment
Airway management (nasal airway), supportive
Plasma concentrate of C1-esterase inhibitor
Epi+antihistamines+steroids
Danazol→ increases synthesis of C1-esterase inhibitor
Ecallantide→ kallikrein inhibitor
Icatibant→ bradykinin receptor antagonist
Danazol
increases synthesis of C1-esterase inhibitor for angioedema
Ecallantide
kallikrein inhibitor for angioedema
Icatibant
bradykinin receptor antagonist for angioedema
Bilateral, rapidly spreading submandibular cellulitis, usually originates from 2nd/3rd molars
Ludwig’s angina
What does “angina” mean in Ludwig’s angina?
Suffocating
Ludwig’s Angina presentation
Tongue elevated Pain, trismus Perioral edema Induration of floor of mouth Mediastinitis
What can be seen on CT of Ludwig’s angina?
gas gangrene
narrowing/deformation of airway
Ludwig’s angina treatment
Surgery:
Awake fiberoptic nasal intubation
Awake tracheostomy
Causes of a retropharyngeal abscess
mixed G- and anaerobic bacteria
tonsillitis
otitis media
pharyngeal trauma
retropharyngeal abscess presentation
*odynophagia* Fever, drooling Neck swelling Torticollis Meningismus Cervical LAD Stridor Airway obstruction
Diagnosis of retropharyngeal abscess
Clinical diagnosis
Imaging shows:
Soft tissue lateral neck x-ray: gas or mass
CT neck
retropharyngeal abscess treatment
Airway management
Antibiotics
Admission→ surgical drainage
Epiglottitis is….
Emergency infection of the supraglottic structures: epiglottis, lingual tonsillar area, epiglottic folds, false vocal cords
Who gets epiglottitis?
Generally rare
Ages 2-7 before HIB vaccines
Adults (v rare)
Causes of epiglottitis
HIB
Strep
Staph
Epiglottitis presentation
Abrupt onset (hours) Fever, stridor Toxic appearance Dysphagia Odynophagia Drooling, tripod Cyanosis Altered LOC Airway obstruction
Diagnosis of epiglottitis
Best clinical due to tenuous airway
Soft tissue lateral neck xray (if stable) → thumb sign
Never use tongue blade in throat
Epiglottitis tx
Immediately control airway
3rd generation cephalosporin once airway is secured: Ceftriaxone (Rocephin)
Croup
Benign, self limited inflammatory condition of trachea below level of vocal cords (subglottic)
Croup aka
laryngotracheobronchitis
Cause of croup
Age group
Time of year
Parainfluenza virus, RSV
6mos-3 years, up to 15 years
Winter
Croup presentation
2-3 day history of URI Low grade fever Barking seal cough (esp at night) Stridor, dyspnea Retractions, Tachypnea
Croup diagnosis
Clinical diagnosis
PA CXR→ steeple sign
not sensitive or specific
Croup tx
Airway management, cool mist, O2
Nebulized epi→ observe 3-4 hours
Steroids:
Prednisolone 1mg/kg
Dexamethasone .15-.6 mg/kg IM or PO (max 10 mg, lasts 56 hours)
Whooping cough aka
Pertussis
Whooping cough is…
Caused by:
Seasonality:
Seen in:
Bordetella pertussis: G- aerob
Cycles every 4-5 years
DPT vax doesn’t protect after 10 years
Highest risk: unvaccinated infants and toddlers
Whooping cough symptoms
URI symptoms (early)
No fever
Paroxysms of coughing (late) → post-tussive vomiting
Inspiratory stridor (young)
Whooping cough tx
Highly contagious→ treat unprotected contacts→ erythromycin/azithromycin
Risk of sudden infant death and airway compromise (unvaccinated)
Diagnose whooping cough..
Leukocytosis (>20K)
Lymphocytosis
Gold standard: nasopharyngeal swab on special culture media
PCR (quicker)
How do lower respiratory tract infections occur, and what general symptoms might be seen?
URI moves to lower respiratory tract
dyspnea
hypoxemia
apnea
acute respiratory failure
Most common lower respiratory tract infection
Bronchiolitis
Bronchiolitis is…
Submucosal edema→ bronchial obstruction
Mucous plugging
Bronchoconstriction
Who gets bronchiolitis and at what time of year?
Infancy, M>F
0-2 years, peak 2-6 months
winter
Bronchiolitis symptoms
Rapid respiration Chest retractions Wheezing Runny nose, sneezing Low grade fever Dyspnea, tachypnea Intercostal retractions Cyanosis, Apnea
Bronchiolitis diagnosis
Clinical diagnosis
Pulse ox→ hypoxia
Viral cultures/fluorescent monoclonal antibody
When to order a CXR for bronchiolitis?
What will it show?
Increased temp Choking Asymmetric chest exam Respiratory distress Sudden deterioration
Shows hyper-inflated lungs
Bronchiolitis can be treated at home with observation if….
Non-toxic
RR<40
no retractions or hypoxia
If bronchiolitis is too severe to observe at home…
Airway management, support Admit Oxygen Beta 2 agonists NO steroids
If a bronchiolitis patient is intubated or severely ill
Ribavirin
Asthma presentation
+/- Auscultate wheezing (see quiet chest)
Accessory muscles or nasal flaring
Altered LOC
“Quiet chest”
Asthma
hypoventilation due to inflammation
Don’t be foooooooled
Asthma treatment
Airway management, O2
B2 agonists: nebulized SVN albuterol→ bronchodilation
Steroids:
→ PO: Prednisone, prelone
→ IV: Solumedrol
Anticholinergics: nebulized atrovent-ipratropium bromide
SVN means
Small volume nebulizer
Decision to admit or discharge asthma
Must be made within 1 hour
What could cause an acute exacerbation of asthma?
Underlying infection
Underlying factors
Clinical decision making for acute exacerbation of asthma?
Admit or discharge? Baseline respiratory distress? Vulnerable population? Improvement with SVN? Able to follow up? Follow instructions?
Acute exacerbation of asthma treatment
Stacked SVN:
.5 cc albuterol in 2.5 cc normal saline
3 tx q 30 minutes
+/- Steroids
Status asthmaticus is defined as
Respiratory failure
FEV1 that doesn’t increase to >40% predicted with treatment
Major complication of status asthmaticus
Pneumothorax
Status asthmaticus tx
Beta agonists
High dose steroids
O2
ADMIT
Pneumonia definition
Inflammation of the lung caused by infection which causes the alveoli to become filled with pus→ excludes air
Pneumonia presentation
Fever, cough
Dyspnea
Pleuritic chest pain
Respiratory failure
Pneumonia diagnosis
Auscultate CXR ABG, pulse ox CBC, blood culture Sputum gram stain, C+S
Pneumonia management
Airway management O2 Abx B2 agonists Analgesics
Pneumothorax presentation
Chest pain on side of collapsed lung
Dyspnea, +/- Cough
Pneumothorax diagnosis
Decreased breath sounds tachypnea, tachycardia Hypotension, cyanosis Marked resp distress Tracheal deviation to opposite side CXR shows absence of lung markings
Pneumothorax tx if <15-20% involvement
observation
repeat CXR in 48 hours
Pneumothorax tx if >20% involvement
Intervention
Simple aspiration
Tube thoracostomy
Tension pneumothorax intervention if >20% involvement
needle decompression at 5th intercostal space, mid-axillary line
