Lecture 8: Dyspnea in the ED Flashcards
What S/S suggest dyspnea?
- Tachypnea/tachycardia
- Stridor
- Accessory muscle use (need pt undressed to see)
- Inability to speak
- Agitation/lethargy
- Depressed consciousness
- Paradoxical abdominal wall movement
What previous medication use is very pertinent to dyspnea evaluation?
Steroid use
What does a history of mechanical ventilation suggest for prognosis of current evaluation of dyspnea?
They will probably need ventilation AGAIN
What abdominal finding might be seen in PE for dyspnea?
Hepatomegaly/congestion
What is one of the earliest signs of hypoxia?
Acrocyanosis
What are the most immediate life-threatening causes of dyspnea?
- Upper airway obstruction
- Tension pneumo
- Pulmonary embolism
- Neuromuscular weakness (Myasthenia gravis, GBS, botulism)
- Fat embolism
What are the MCC of dyspnea?
- COPD
- Decompensated HF
- Ischemic heart disease
- PNA
- Psychogenic
What symptoms suggest HF as underlying etiology for dyspnea?
- PND
- Orthopnea
- Edema
- DOE
What diagnostic helps differentiate COPD/asthma from other disorders?
Decreased peak expiratory flow rate
What easy and quick diagnostic can help differentitate between acute cardiac vs noncardiac causes?
Bedside POCUS
Initial approach to managing dyspnea?
Maintain oxygenation
Treat O2 sat first!
Goals for hypoxia
- PaO2 > 60 mmHg
- O2 sat > 90%
What might cause us to keep O2 at a lower goal?
CO2 retainers, since they are chronically hypercapnic
They have a lower baseline!
What is the progression of o2 delivery?
- NC (0.25-4)
- Simple mask (6-10)
- NRB (10-15)
- HF NC (40 or higher is possible)
High flow NC has positive pressure as well
NRB is generally short-term, transitioning to ETT
What are the options for noninvasive ventilation?
- CPAP
- BiPAP
Use BiPAP if pt feels like they are suffocating against CPAP
MC sign of an upper airway obstruction
Stridor
MCC of stridor in a neonate?
Laryngotracheomalacia (weak larynx)
What should we always consider as a cause of stridor in kids?
- Food and toys
- MC in ages 1-3
How would a kid with a FB in their larynx/trachea present?
- Stridor
- Hoarseness
- Complete apnea
How does a FB in the bronchi present for children?
- Unilateral wheezing
- Decreased breath sounds
MC location for a FB in a child to cause choking?
Bronchial
MC foods for a kid to choke on
- Peanuts
- Sunflower sseeds
- Carrots (raw)
- Raisins
- Grapes
- Hot dogs
Aka things that cant be chewed up well
How do we approach tx of a suspected airway FB?
- Life-saving interventions FIRST
- Imaging
- Bronchoscopy to confirm/rule out/remove FB
Specifically for a bronchial FB, what views can help assess air trapping?
Inspiratory and expiratory PA views
What imaging is indicated for a tracheal FB?
PA and lateral soft tissue neck
What might suggest radiolucent FB on CXR?
- Unilateral obstructive emphysema with air trapping and mediastinal shift away
- Focal atelectasis with complete obstructions
- Consolidation => scarring
Describe a coin in the trachea
- PA/AP will show its side
- Lateral will shows its face
- tcl (Trachea coin lateral)
Describe a coin in the esophagus
- 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
Management of airway FB with complete obstruction
- BLS
- Direct laryngoscopy with FB extraction
- Orotracheal intubation to dislodge FB if ^ fails
- If ETT fails, needle cricothyroidotomy/tracheostomy
- Consult pulm for emergency bronchoscopy if all else fails
Management of airway FB with only partial obstruction
Bronchscopy under general anesthesia
Prodrome of Croup/laryngotracheobronchitis
- Cough
- Coryza
- Mild fever
Croup is VIRAL
Classic presentation of Croup
- Inspiratory stridor
- Barking
- Seal like cough
Croup is VIRAL
Severities of Croup
- Mild: no stridor at rest
- Mod: Stridor at rest and mild retractions
- Severe: Stridor at rest + severe retractions + anxious + fatigued
Although imaging is not necessary to diagnose classic croup, what can we order and what would we see?
- Soft tissue neck XR
- Steeple sign with normal epiglottitis
- Narrowing of superior trachea
- Subglottic haziness
Tx of mild croup
- Outpatient
- Single dose of oral dexamethasone
- Alternatives: IM dexa or neb budesonide
Tx of mod-sev Croup
- 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
Discharge criteria for croup
Must meet all
- Nontoxic
- No dehydration
- O2 > 90% on RA
- Reliable caregiver
- Obs with improvement for 3 hrs post last epi
- f/u in 24-48h with PCP
Must meet ALL
Admission indications for croup
Just meet 1
- Persistent stridor at rest
- Tachypnea
- Retractions
- Hypoxia
- > 2 doses of nebulized epi are needed
Meet 1
Difference between bacterial tracheitis vs croup
- More severe resp distress
- Toxic appearing
- Thick, mucopurulent secretions causing upper airway obstruction
- Sore throat: tenderness to trachea on palpation
Dx of Bacterial tracheitis
- Clinical (similar to how we dx croup)
- Bronchoscopy after airway secure
Neck XR will show steeple sign ALSO
What are the goals of bronchoscopy for bacterial tracheitis?
- Confirmation of edema of trachea
- Therapeutic removal of mucus
- C&S of secretions
What do the kidneys regulate in terms of acid-base?
- HCO3- (base/alkalotic)
- Compensation takes 12-24 hours to occur
AKA respiratory acidosis is hard to correct quickly.
What do the lungs regulate in terms of acid-base?
- PCO2 (acid)
- Compensation occurs within minutes
Why does aloveolar hypoventilation result in respiratory acidosis?
Preventing the CO2 from exchanging properly.
So you can’t get CO2 out
Acute causes of respiratory acidosis
- Head trauma
- Chest trauma
- Lung disease
- Excess Sedation
What occurs that switches breathing to having a hypoxic drive?
Chronic PCO2 > 60-70 mmHg can depress the respiratory center.
HOWEVER, do not withhold O2 in pts if severely dyspneic.
What secondary condition can result from alveolar hyperventilation/respiratory alkalosis?
Ionized hypocalcemia.
Why do we give panic attacks a bag to breathe in?
Rebreathing their own CO2 so that they don’t become alkalotic.
What PESI score suggests inpatient admission?
PE Severity Index
At least 1 or more.
