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Emergency Medicine > Lecture 8: Dyspnea in the ED > Flashcards

Lecture 8: Dyspnea in the ED Flashcards

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Royal College: Emergency Medicine flashcards
1
Q

What S/S suggest dyspnea?

A
  • Tachypnea/tachycardia
  • Stridor
  • Accessory muscle use (need pt undressed to see)
  • Inability to speak
  • Agitation/lethargy
  • Depressed consciousness
  • Paradoxical abdominal wall movement
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2
Q

What previous medication use is very pertinent to dyspnea evaluation?

A

Steroid use

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3
Q

What does a history of mechanical ventilation suggest for prognosis of current evaluation of dyspnea?

A

They will probably need ventilation AGAIN

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4
Q

What abdominal finding might be seen in PE for dyspnea?

A

Hepatomegaly/congestion

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5
Q

What is one of the earliest signs of hypoxia?

A

Acrocyanosis

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6
Q

What are the most immediate life-threatening causes of dyspnea?

A
  • Upper airway obstruction
  • Tension pneumo
  • Pulmonary embolism
  • Neuromuscular weakness (Myasthenia gravis, GBS, botulism)
  • Fat embolism
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7
Q

What are the MCC of dyspnea?

A
  • COPD
  • Decompensated HF
  • Ischemic heart disease
  • PNA
  • Psychogenic
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8
Q

What symptoms suggest HF as underlying etiology for dyspnea?

A
  • PND
  • Orthopnea
  • Edema
  • DOE
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9
Q

What diagnostic helps differentiate COPD/asthma from other disorders?

A

Decreased peak expiratory flow rate

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10
Q

What easy and quick diagnostic can help differentitate between acute cardiac vs noncardiac causes?

A

Bedside POCUS

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11
Q

Initial approach to managing dyspnea?

A

Maintain oxygenation

Treat O2 sat first!

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12
Q

Goals for hypoxia

A
  • PaO2 > 60 mmHg
  • O2 sat > 90%
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13
Q

What might cause us to keep O2 at a lower goal?

A

CO2 retainers, since they are chronically hypercapnic

They have a lower baseline!

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14
Q

What is the progression of o2 delivery?

A
  1. NC (0.25-4)
  2. Simple mask (6-10)
  3. NRB (10-15)
  4. HF NC (40 or higher is possible)

High flow NC has positive pressure as well

NRB is generally short-term, transitioning to ETT

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15
Q

What are the options for noninvasive ventilation?

A
  • CPAP
  • BiPAP

Use BiPAP if pt feels like they are suffocating against CPAP

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16
Q

MC sign of an upper airway obstruction

A

Stridor

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17
Q

MCC of stridor in a neonate?

A

Laryngotracheomalacia (weak larynx)

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18
Q

What should we always consider as a cause of stridor in kids?

A
  • Food and toys
  • MC in ages 1-3
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19
Q

How would a kid with a FB in their larynx/trachea present?

A
  • Stridor
  • Hoarseness
  • Complete apnea
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20
Q

How does a FB in the bronchi present for children?

A
  • Unilateral wheezing
  • Decreased breath sounds
21
Q

MC location for a FB in a child to cause choking?

A

Bronchial

22
Q

MC foods for a kid to choke on

A
  • Peanuts
  • Sunflower sseeds
  • Carrots (raw)
  • Raisins
  • Grapes
  • Hot dogs

Aka things that cant be chewed up well

23
Q

How do we approach tx of a suspected airway FB?

A
  • Life-saving interventions FIRST
  • Imaging
  • Bronchoscopy to confirm/rule out/remove FB
24
Q

Specifically for a bronchial FB, what views can help assess air trapping?

A

Inspiratory and expiratory PA views

25
Q

What imaging is indicated for a tracheal FB?

A

PA and lateral soft tissue neck

26
Q

What might suggest radiolucent FB on CXR?

A
  • Unilateral obstructive emphysema with air trapping and mediastinal shift away
  • Focal atelectasis with complete obstructions
  • Consolidation => scarring
27
Q

Describe a coin in the trachea

A
  • PA/AP will show its side
  • Lateral will shows its face
  • tcl (Trachea coin lateral)
28
Q

Describe a coin in the esophagus

A
  • AP/PA shows the coin face
  • Lateral shows the coin side
  • ecap (esophagus coin on AP)

Esophagus is wide for food, so it shows the big side of the coin

29
Q

Management of airway FB with complete obstruction

A
  1. BLS
  2. Direct laryngoscopy with FB extraction
  3. Orotracheal intubation to dislodge FB if ^ fails
  4. If ETT fails, needle cricothyroidotomy/tracheostomy
  5. Consult pulm for emergency bronchoscopy if all else fails
30
Q

Management of airway FB with only partial obstruction

A

Bronchscopy under general anesthesia

31
Q

Prodrome of Croup/laryngotracheobronchitis

A
  • Cough
  • Coryza
  • Mild fever

Croup is VIRAL

32
Q

Classic presentation of Croup

A
  • Inspiratory stridor
  • Barking
  • Seal like cough

Croup is VIRAL

33
Q

Severities of Croup

A
  • Mild: no stridor at rest
  • Mod: Stridor at rest and mild retractions
  • Severe: Stridor at rest + severe retractions + anxious + fatigued
34
Q

Although imaging is not necessary to diagnose classic croup, what can we order and what would we see?

A
  • Soft tissue neck XR
  • Steeple sign with normal epiglottitis
  • Narrowing of superior trachea
  • Subglottic haziness
35
Q

Tx of mild croup

A
  • Outpatient
  • Single dose of oral dexamethasone
  • Alternatives: IM dexa or neb budesonide
36
Q

Tx of mod-sev Croup

A
  • Single dose dexamethasone
  • Nebulized/racemic epinephrine
  • Humidified O2
  • Heliox if above fails
  • ETT last resort if everything else fails

Heliox is 70-80% helium + 20-30% O2

37
Q

Discharge criteria for croup

Must meet all

A
  1. Nontoxic
  2. No dehydration
  3. O2 > 90% on RA
  4. Reliable caregiver
  5. Obs with improvement for 3 hrs post last epi
  6. f/u in 24-48h with PCP

Must meet ALL

38
Q

Admission indications for croup

Just meet 1

A
  1. Persistent stridor at rest
  2. Tachypnea
  3. Retractions
  4. Hypoxia
  5. > 2 doses of nebulized epi are needed

Meet 1

39
Q

Difference between bacterial tracheitis vs croup

A
  • More severe resp distress
  • Toxic appearing
  • Thick, mucopurulent secretions causing upper airway obstruction
  • Sore throat: tenderness to trachea on palpation
40
Q

Dx of Bacterial tracheitis

A
  • Clinical (similar to how we dx croup)
  • Bronchoscopy after airway secure

Neck XR will show steeple sign ALSO

41
Q

What are the goals of bronchoscopy for bacterial tracheitis?

A
  • Confirmation of edema of trachea
  • Therapeutic removal of mucus
  • C&S of secretions
42
Q

What do the kidneys regulate in terms of acid-base?

A
  • HCO3- (base/alkalotic)
  • Compensation takes 12-24 hours to occur

AKA respiratory acidosis is hard to correct quickly.

43
Q

What do the lungs regulate in terms of acid-base?

A
  • PCO2 (acid)
  • Compensation occurs within minutes
44
Q

Why does aloveolar hypoventilation result in respiratory acidosis?

A

Preventing the CO2 from exchanging properly.

So you can’t get CO2 out

45
Q

Acute causes of respiratory acidosis

A
  • Head trauma
  • Chest trauma
  • Lung disease
  • Excess Sedation
46
Q

What occurs that switches breathing to having a hypoxic drive?

A

Chronic PCO2 > 60-70 mmHg can depress the respiratory center.

HOWEVER, do not withhold O2 in pts if severely dyspneic.

47
Q

What secondary condition can result from alveolar hyperventilation/respiratory alkalosis?

A

Ionized hypocalcemia.

48
Q

Why do we give panic attacks a bag to breathe in?

A

Rebreathing their own CO2 so that they don’t become alkalotic.

49
Q

What PESI score suggests inpatient admission?

PE Severity Index

A

At least 1 or more.

Emergency Medicine (29 decks)

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