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Emergency Medicine > Lecture 8: Dyspnea Readings > Flashcards

Lecture 8: Dyspnea Readings Flashcards

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Royal College: Emergency Medicine flashcards
1
Q

Classifications of Acute HF

A
  1. HTN acute HF: preserved LVEF, SBP > 140, Pulm edema
  2. Pulmonary edema
  3. Cardiogenic shock: hypoperfusion + SBP < 90
  4. Acute on chronic HF: SBP 90-140, mild-mod S/S, takes days
  5. RHF: low output, JVD, hepatomegaly, hypotension
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2
Q

Top symptom for acute heart failure

A

DOE

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3
Q

Top 3 symptoms generally unique to acute HF

A
  1. PND
  2. Orthopnea
  3. Edema
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4
Q

CXR findings for acute HF

A
  • Pulmonary venous congestion
  • Cardiomegaly
  • Interstitial edema

Most specific

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5
Q

Management of acute HF

A
  1. O2 > 95%
  2. Afterload reduction if pulm edema present
  3. NTG based on BP
  4. Nitroprusside if ^ fails
  5. Loop diuretics for volume overload
  6. Persistent hypotension post ntg = bolus NS
  7. Morphine (debateable, but can relieve anxiety/congestion)
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6
Q

High-risk patient characteristics for acute HF that may suggest ICU

A
  • AMS
  • Persistent hypoxia
  • Hypotension
  • Trop elevation
  • Ischemic EKG changes
  • BUN > 43
  • Cr > 2.75
  • Oliguria
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7
Q

Top 2 MC symptoms in a PE

A
  • Dyspnea
  • Pleuritic chest pain
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8
Q

Criterias used for evaluating PE

A
  • PERC Rules (all 9 to r/o PE)
  • Wells’ score

Do Well’s first! Low risk well’s => PERC

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9
Q

Wells’ score breakdown for PE

A
  • > 6 = HIGH RISK
  • 2-6 = mod
  • < 2 = low-risk

Low = do PERC
Mod = D-dimer vs CTA
High = CTA

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10
Q

Test of choice to diagnose PE

A

CT pulmonary angiography aka pulm CTA

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11
Q

What finding on a V/Q scan has a 100% sensitivity to r/o PE?

A

Homogenous scintillation

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12
Q

Sample PE algorithm

A
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13
Q

What kind of pt with a PE should NOT use LWMH?

A

Severe renal insufficiency

Use UFH instead

LWMH works for Liver impairment

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14
Q

What are the primary outpatient tx options for a PE?

A
  • LWMH
  • Xarelto
  • Eliquis
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15
Q

When are systemic thrombolytics indicated for PE?

Only alteplase approved

A
  • Hypotension < 90
  • BP dropped by > 40

Start UFH or LWMH after

Either indication

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16
Q

When is IVC filter indicated for PE?

A
  • AC is contraindicated or failed
  • Submassive PE associated with DVT
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17
Q

MCC of bronchitis

A
  • Flu A/B
  • Adeno
  • Rhino
  • Parainfluenza
  • RSV
  • Corona

VIRAL

Bacterial is way rarer

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18
Q

Predominant feature of acute bronchitis

A

Coughing (productive just suggests inflammation)

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19
Q

Clinical diagnosis of acute bronchitis

A
  1. Acute-onset cough < 3 weeks
  2. Absence of chronic lung disease
  3. Normal vitals
  4. Absence of pneumonia lung sounds
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20
Q

If we suspect pertussis instead of bronchitis, what is the tx?

A

Azithromycin

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21
Q

When are BDs indicated for acute bronchitis?

A
  • Evidence of airflow obstruction
  • Give some albuterol
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22
Q

MCC of classic pneumonia

A

Strep pneumo

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23
Q

What history suggests bacterial PNA is due to an anaerobe?

A

Aspiration

24
Q

S/S of bacterial PNA

A
  • Cough/fatigue/fever/dyspnea
  • Sputum production
  • Pleuritic chest pain
  • Tachypnea/tachycardia
  • Bronchial breath sounds + rhonchi => consolidation
25
Q

What makes bacterial PNA considered healthcare associated?

A
  • Hospitalized for > 48h in past 90d
  • Dialysis/wound care/SNF
  • Home IV Abx therapy
26
Q

Where does aspiration PNA tend to consolidate?

A

RLL due to gravity and bronchial tree

Will lead to empyema or abscess

27
Q

ABX for uncomplicated, outpatient CAP

A

azithromycin or doxycycline

Tintinalli’s only, guidelines were updated!

28
Q

ABX for comorbidities, outpatient CAP

A
  • Levofloxacin
  • Augmentin + azithromycin/doxy

Oral FQs are used after macrolide failure usually.

Normal OP is just azithro or doxy, so augmentin for an augmented patient

29
Q

ABX for inpatient CAP (but not ICU)

A
  • Levofloxacin
  • Rocephin + Azithromycin
30
Q

ABX for inpatient ICU CAP

A
  • Rocephin + levofloxacin +/- vanco (MRSA)

Just a combo of both inpatient options

31
Q

ABX for inpatient HCAP

A
  • Levofloxacin + cefepime/piptazo
  • Also add vanco or linezolid
32
Q

ABX for witnessed aspiration PNA

A
  1. Immediate tracheal suction
  2. Bronchoscopy
  3. Levofloxacin + clinda (abscess)
33
Q

ABX for empyema

A
  • Piptazo
  • Add vanco for MRSA
34
Q

ABX for lung abscess

A

Clinda + rocephin

CRAL

35
Q

MC 2 symptoms and MC sign for pneumothorax

A
  • Suddet onset dyspnea
  • Ipsilateral pleuritic chest pain
  • Sinus Tachycardia
36
Q

In what type of pneumothorax are ipsilateral decreased breath sounds likely to occur?

A

Traumatic pneumothorax

37
Q

Clinical hallmarks of tension pneumothorax

A
  • Severe, progressive dyspnea
  • Tachycardia > 140
  • Hypoxia
  • Ipsilateral decreased breath sounds

Tracheal deviation, distended neck veins, and PMI displacement are late and infrequent.

38
Q

Primary imaging for a stable pneumothorax pt

A

PA CXR showing displaced pleural line with absent lung markings.

39
Q

What signs on a supine AP CXR suggest pneumothorax?

A
  • Cardiophrenic recess hyperlucency
  • CPA enlargement (deep sulcus sign)
40
Q

How do we confirm a emphysematous bulla vs a pneumothorax?

A

CT Chest

41
Q

Quick and easy Imaging for a young, healthy patient with pneumothorax?

A

Bedside US

42
Q

Management of pneumothorax

A
  • Tension: needle decompression + tube thoracostomy
  • 2-4 LPM of O2 to help pleural air resorption
  • If small: monitor for 4 hrs on supplemental O2 and repeat CXR. Improved = 24h f/u.
  • Aspiration for small primary or secondary
  • Chest tube thoracostomy for big or recurrent, also admit
43
Q

Where is needle aspiration done for pneumothorax?

A
  • Anterior 2nd ICS at midclavicular
  • Laterally in 4/5th ICS anterior axillary

14G, 2 in needle, 18G in children

44
Q

Two main forms of COPD

A
  • Emphysema
  • Chronic bronchitis
45
Q

Main physiologic cause of acute asthma exacerbations vs COPD exacerbations

A
  • Asthma exacerbation: Expiratory airflow is limited
  • COPD exacerbation: V/Q mismatch
46
Q

RFs for death from asthma exacerbation?

A
  1. 2+ admits or 3+ ER visits for asthma in past year
  2. > 2 canisters of SABAs a month
  3. Poor, drugs, psych
47
Q

Hypoxia S/S

A
  • Tachypnea
  • Cyanosis
  • Agitation
  • Apprehension
  • Tachycardia
  • HTN
48
Q

Hypercapnia S/S

A
  • AMS
  • Plethora
  • Stupor
  • Hypopnea
  • Apnea
49
Q

How is asthma severity measured?

A
  • FEV1
  • Peak expiratory flow rate

< 40% in either = severe

50
Q

Management of acute asthma/COPD exacerbations

A
  • O2 > 90%
  • SABAs for bronchospasms (inhaled first)
  • SC SABAs 2nd: terbutaline or epi
  • Adjuvant therapy for SABA: ipratropium
  • Prednisone PO or methylprednisolone in the ED
  • Empiric ABX for COPD with sputum changes. (Doxy/azithro/Augmentin)
  • IV MgSO4 for asthma FEV1 < 25%
  • NPPV if they seem tired af
  • ETT if ^ fails
51
Q

Admission criteria for asthma

A
  • Failed outpatient tx
  • Persistent/worsening dyspnea
  • PEFR/FEV1 < 40%
  • Hypoxia/hypercarbia/AMS
52
Q

Admission criteria for COPD

A
  • Failed outpatient tx
  • Frequent exacerbations post-discharge
  • Severe dyspnea
  • Worsening status
  • Can’t take care of self at home
53
Q

What should you AVOID in asthma/COPD exacerbations?

A
  • Respiatory depression drugs
  • BBs
  • Antihistamines
  • Decongestants
  • Mucolytics
54
Q

What is the role of heliox in asthma/COPD exacerbations?

A

Lower airway resistance to deliver drugs in severe

55
Q

Discharge meds for asthma/COPD exacerbations

A

Oral steroids (5-10d of prednisone)

Emergency Medicine (29 decks)

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