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Emergency Medicine > Pulmonary and CP > Flashcards

Pulmonary and CP Flashcards

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1
Q

approach to pt with mild to moderate Asthma attack

3

A

 Hand held nebulizer – asap Albuterol, Atrovent

 Oral Prednisone (60mg) PO (as good as IV initially)

 Peak flow (PEFR) after each neb tx, repeat VS, reassess

 Usually no need for labs, CXR, EKG, ABG, etc

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2
Q

Discharge

A

 Walk ‘em, assure f/u, return precautions
–> have them speaking mary had a little lamb her fleece was white as snow

 Oral steroid burst (60mg x5d or tapered dose Rx), inhaled steroid Rx

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3
Q

asthma pt can’t go home if

A

 Not responding to treatment, worsening

 Hypoxic - ambulatory pulse ox <95%

 PEFR not improved to 65- 70% predicted

 ED visit in past 3 days for same

 Exacerbation during steroid burst

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4
Q

hallmark of asthma attack

A

bilateral!

if not–> another dz process

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5
Q

Other than wheezing what would we likely see in a pt with an asthma attack

A

Dyspnea, cough, chest “tightness”

Pronged expiratory phase, I:E ratio 1:3 or 4

Tachypnea, tachycardia, HYPOxia, HYPERcarbia

Poor peak expiratory flow measurements (PEFR)

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6
Q

how do you elicit a prolonged expiratory phase

A

blow out the cake with 100 candles

will hear prolonged exasperation

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7
Q

what is a nl peak flow

A

Poor peak expiratory flow measurements (PEFR)

650 or 700 is normal

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8
Q

why do we see asthma exacerbations most commonly in the ED

A

Med non-compliance, viral illness most common reasons

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9
Q

what other pts wheeze

A

CHF
PE
COPD

is the person is over 40 and does not have a dx of asthma WATCH OUT

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10
Q

essential questions for pts with asthma

A

have you had a fever?
have you had any trauma?
have you been sick?
have you had this before?

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11
Q

what is the neb treatment for asthma

A

albuterol neb 2.5 mg

once, 3x q20min or 10ml/1hr

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12
Q

COPD exacerbation will look like (VS)

A

BP 170/95,
P 120,
RR 32/min, (not good!)
T 97

pulse ox 93% on 4L nasal canula. 3-4 word sentences, sweating, insists on sitting upright, leaning forward.

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13
Q

treatment goals for COPD

A

reverse hypoxia, reverse hypercarbia, restore effective ventilation

The retention of CO2 is what brings these people down

pump has to work
alveoli have to work
need to get it out

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14
Q

reasons for COPD exacerbations

A
  1. Disease progression
  2. Med non-compliance, out of home O2
  3. Infection - viral, bronchitis, pneumonia
  4. Cardiac - pump
    failure/impairment, arrhythmia
  5. Metabolic acidosis, other illness on top
  6. Exposure/environment
  7. Sedation, drugs
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15
Q

what do we see on a COPD CXR

A

Hyperexpanded lung fields, narrow cardiac silhouette, flat diaphragms, blunted costophrenic angles

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16
Q

what labs would you want in a COPD exacerbation pt

A

CXR, lung/cardiac US, EKG, monitor, labs

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17
Q

TX COPD

A 
	Continuous nebulizer treatments
             Beta 2 agonists (10mg over 1h)
              Inhaled anticholinergics
	Oral steroids, IV if admit 
	Antibiotics if appropriate
	Assisted ventilation - NIPPV
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18
Q

antibiotic commonly used in COPD pts

A

doxy

they get the weird bugs

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19
Q

when can you NOT send a COPD pt home

A 
	Not responding, worsening symptoms/signs
	Mental status changes
     If they require a bipap
	Hx recent severe exacerbations/intubation
	Older, co-morbidities
	New arrhythmia
	Uncertain of diagnosis
	Poor ambulatory pulse ox
	Poor home support
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20
Q

presentation of pneumothorax

A

elevated RR
elevated pulse
94% Room air
sudden

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21
Q

focused Hx for pneumothorax

A

have you had this before?
cardiac and pulm ROS
PMH
trauma? syncope?

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22
Q

Pulmonary ROS

A

Cough? Sputum? Hemoptysis?
o Coughing up blood?
• Shortness of breath (SOB = dyspnea)? • Wheezing?
• Pleurisy?

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23
Q

Cardiac ROS

A 
Chest pain?
• Palpitations?
• Dyspnea on exertion DOE? o SOB on exertion?
• Orthopnea?
o SOB when lying down?
• Paroxysmal nocturnal dyspnea PND?
o Do you awake in the middle of the
night and feel like you have to run
to the window to get air?
• Leg edema?
o Swelling in legs?
• Hx of cardiac problems? (HTN, MI, CHF,
rheumatic fever, heart murmur)?
o **Move to PMH if positive
• Ever had/last EKG?
o **Move to HM: Screening
• Ever had/last heart tests (echo, stress
tests)?
o **Move to HM: Screening
• Cardiac procedures (cath, stent)
o **Move to PMH: Surgeries if yes
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24
Q

What do you do for suspected pneumothorax

A

i. IV, O2, monitor; EKG, tx pain
ii. CXR – search edges
1. +/-Expir film, lateral decub; deep sulcus sign if in bed
iii. Bedside ultrasound

looking for absence of “comet tailing”; the friction of pleural sliding

Shock? Or stable now?

  1. Can deteriorate quickly
  2. Could be obstructive shock
    v. Primary or Secondary?
  3. Primary pneumo –> spontaneous
  4. Secondary pneumo —>a result of something

chest CT
surgery consult

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25
Q

Tx for pneumothorax

A
  1. Treatment depends on size
    Pigtail catheter w/ Heimlich valve
    Chest tube
  2. Small, primary pneumos (<15% total lung) in select cases, a stable patient can go home if:
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26
Q

when can a pneumothorax go home

A

with a pigtail

Not a secondary pneumo

b. Stable vitals after 3-4hrs
c. Repeat CXR with no enlargement
d. Pt is reliably able to return in 12-24hrs for repeat CXR
e. If catheter re-expansion
i. Stable x6hrs
f. Surgical consult agrees

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27
Q

tension pneumothorax is dx

A

CLINCALLY

pt will die if not treated

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28
Q

Pt presentation of pneumothorax (5)

A

Pt with trauma to the chest

  1. Severe dyspnea, sudden change in VS/LOC
  2. *Decreased breath sounds affected side
  3. *Hypotension
  4. *Distended neck veins
  5. *Tracheal shift (late)
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29
Q

what is the Tx for tension pneumothorax

A

iv. Needle thoracentesis: 2nd ICS at MCL

with 16 gauge at second intercostal space mid-clavicular line

v. Follow with chest tube immediately

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30
Q

a. A 54yo woman, hx of breast CA, BIB family. The pt has “not left her bed” and has been c/o chest pain for the past 2 days and seems to be “breathing fast”. Family states chemo/radiation ended 4mos ago. Patient is thin, appears ill, is not talking.
Vitals: BP 108/60, P 110, RR 28, T 99.3 (not a fever), 93% on room air

what is supected in the pt and why

A

Don’t know yet DDx? PE, sepsis, malnutrition/dehydration, is she in hypovolemic shock?

PE and pulmonary effusion are at the top b/c of hx of chemo

BP is low 
P 100
RR 28 
T 99.3
93% on room air

IV, OT MONITOR

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31
Q

Pulmonary Effusion workup

A

i. IV, O2, monitor, pain control, labs
ii. CXR; Lateral decubitus film – does it layer out?
iii. Bedside ultrasound - see fluid, guides tap – also check for pericardial effusion
iv. Chest CT - gold standard

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32
Q

if you have a pulmonary effusion you need to look for

A

pericardial effusion -triple scan

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33
Q

what can a CT tell us about a pulmonary effusion

A
  1. Excellent for small effusions, other dx’s
  2. CT guided thoracentesis if loculated – doesn’t layer out
  3. Effusions can be infectious, malignant, reactive, chronic, post-surgical, traumatic
34
Q

TX for pleural effusion

A
  1. Sick? Is this shock? Fever?
  2. Triple scan US: fluid status, pericardial effusion
  3. US guided Thoracentesis
    Diagnostic and therapeutic
    Slow removal of fluid - ultrasound guided`
    No more than 1000 - 1500ml
    To avoid re-expansion pulmonary edema
    CXR after to check for pneumothorax
  4. Pleural fluid analysis
35
Q

Thoracentesis for pleural effusion

A

diagnostic and therapeutic

36
Q

who are you worried about in flu season

A

Young, old, immunocomp, recent surg/hosp, lung Dz

37
Q

who gets a CXR with the flu

A
  1. Hypotension/tachy/tachy, hypoxic, lung findings
  2. No viral syndrome sx’s, worsening (We are worried about PNA)
    sxs for more than 2 weeks
38
Q

who get moved to maintain to the ED

A

Abnormal VS, chest pain, young/old, risks, look sick

39
Q

Which Hx/PE findings really make a difference in a pt with suspected flu

A
  1. ROS: SOB, DOE, hemoptysis, leg edema/pain, syncope
  2. PMHx (cardiac, lung dz, DM, steroids), SH (etoh, homeless)
  3. VS, diaphoresis, new wheezes, rales, edema, rash
40
Q

Who has the flu vs. who has pneumonia, other dx??

A
  1. Bacteria/pneumonia is very narrow minded and tends to stay in one spot
  2. Flu gives you symptoms all over – malaise, sore throat, fever, vomiting, maybe diarrhea (viruses affect a lot of different systems)
41
Q
  1. CURB65
A

helps predict mortality in a person with pneumonia

CONFUSION
BUN
RR
BP
OVER 65
42
Q

TX for pneumo

A

v. Abx:
Azithro mostly

Levo?, Doxy

43
Q

MCC of hemoptysis

A
  1. Pneumonia = MCC
  2. Coumadin
  3. Tuberculosis
  4. Cancer
  5. Pulmonary embolus
  6. Hematemesis?
  7. Nasal, dental, oral source?
  8. Trauma
44
Q

how does hemodynamically stable help us figure out hemoptysis
1:00hr

A

iii. Hemodynamically stable?
Hemodynamically unstable patients don’t have enough pressure in the circulatory system to keep blood flowing

Pale and cool skin
Diaphoresis (sweating)
Fatigue
Very fast or very slow pulse (fast can be either a reaction to or a cause of instability; slow is almost always a cause)
Low blood pressure (very late sign)
Shortness of breath (not enough blood getting to the lungs)
Chest pain (could be related to inadequate blood flow in the heart)
Confusion (probably comes after the blood pressure drops)
Loss of consciousness (syncope, which is bad)

45
Q

what diagnostic tests should we be running for hemoptysis

A

 ABC’s, vitals; IV(s), O2, monitor
 Hx: Onset? Chest pain? SOB? Weight loss? Fever? Trauma? Coumadin? CAM?
 PE: Usual suspects + look for non-pulmonary source

 CXR, EKG, Labs, lactic acid, PT/INR. Type and screen/cross?
 Chest CT if significant, stable

 If very significant, ongoing: a big airway concern (blood is coming from the airway). Make a plan

everybody needs to be in the room. need a bronch

 Pulmonary consult: bronchoscopy

46
Q

f. HIV w/ infiltrates-what diagnostic tests would you want

A 
CXR
Labs:
lactic acid
 LDH-helps predict severity
cultures
 HIV labs:  CD4 count, viral load
47
Q

when is an HIV pt considered immunocompetent

A
  1. CD4 >200 = immunocompetent
48
Q

i. Clinical Presentation of TB

A

Cough, fever, weight loss, fatigue, night sweats, pleuritic chest pain, dyspnea and hemoptysis.

49
Q

Risks for TB

A

Classic sx’s, endemic area of origin - travel

Risks: immunocomp, incarcerated, known exposure, homeless, EtOH

50
Q
  1. Lung exam in a pt w/ TB
A

can’t be diagnosed
variable

need CXR and labs

51
Q

CXR presentations of TB

A

a. Infiltrates/consolidation
b. Reactivation favors upper lobes
c. Pleural effusion
d. Cavitary lesions
e. Calcifications
f. Miliary pattern

52
Q

what do you do with TB in the ED

A

if in respiratory distress–> ADMIT

if high risk (+ PPD, hx of exposure, alcoholic, incarcerated, form endemic area)

if your CXR has ANY infiltrate of effusion –> ADMIT

53
Q

positive PPD hx with clean CXR and sxs of TB

A

ADMIT

54
Q

+PPD, CXR, NO sxs

A

home

PCP or TB coordinator f/u and intiate tx
ED does not initiate tx

55
Q

a. A 73yo F w/ Hx HTN, DM, BIB ambulance c/o 2d of increasing “breathlessness”, now with slight exertion, and chest “tightness”. She looks pale, anxious and uncomfortable.

Vitals: BP 182/112, P 118, RR 28, afebrile, pulse ox 94% on non-rebreather mask.

what’s your ddx

A 
	CHF
	AMI/ACS
	PE
	Pericardial effusion	
	Infection
	Pleural effusion
	Renal failure
	Cancer
56
Q

A 73yo F w/ Hx HTN, DM, BIB ambulance c/o 2d of increasing “breathlessness”, now with slight exertion, and chest “tightness”. She looks pale, anxious and uncomfortable.

what do you do for this pt

A

Begin with: IV, O2, monitor, EKG, CXR, Triple scan US

Labs, lactic acid, troponin, UA, Tox screen
Careful Hx & PE when stable

she’s probably acidotic and we already know where we are going to start with her
BNP is $$$$$

57
Q

TX for CHF

A
  1. LMNOP-N
Lasixs
Morphine
NTG
O2
Position
NIPPV
  1. -Diuretics: Lasix
  2. -Vasodilators – NITRO IV reduce preload, afterload:
  3. Morphine +/-, Nitrates
  4. -Oxygen, Position
  5. -NIPPV is awesome
  6. -US better than BNP in ED unless Dx uncertain
  7. -Admit all new CHF – search for cause
  8. -Admit moderate, severe, recurrent, unstable
  9. B lines on lung U/S
58
Q

how should we think about CHF

A

structural functional inability to fill and pump
can be acute or chronic

acute: flash pulmonary edema, L-sided MI, HTN emergency, valve rupture
chronic: HTN, valve dz, CAD–> cardiomegaly, mitral regurg

59
Q

three questions we need for CHF

A

R or L or both
systolic or diastolic
high or low output failure

60
Q

left sided Heart failure looks like

A 
DOE
cough
fatigue
orthopnea
PND
rales
S3 gallop
61
Q

right sided looks like

A

JVD
peripheral edema
hepatomegaly
anascara

62
Q

systolic looks like

A

can’t squeeze enough

63
Q

diastolic HF looks like

A

can’t relax to fill

64
Q

low output failure

A

common chronic CHF low EF

65
Q

high output failure

A

compensating for demand
thyroid storm
anemia etc

66
Q

when do we NOT GIVE NITRO for CHF pt

A 
right sided inferior MI
viagra
tamponade
aortic stenosis
or hypovolemia
67
Q

47 yo female self presents to the ED c/o increasing DOE and dizziness for 1 week. No PMH. Triage vitals: BP 132/88, P 104, RR 20, afebrile, pulse ox is 98% on ra.

A

pulse a little high
RR pretty high

CXR–>good
Pulse OX–> good
get a Hgb 6.2 hct 20%

68
Q

when do we see anemia sxs and what do they look like

A

when compensation fails

i. When compensation fails = Sx’s: DOE, dizzy, weak, malaise, palpitations, chest pain, syncope

69
Q

tx for symptomatic anemia

A

blood

need occult blood test
MCC- menstration
need CA workup

So…why is this patient anemic?? Melena? Menstrual? Cancer? Renal Failure? Iron? Macro- or Microcytic?

70
Q

40yo F c/o 4 hours of sharp, L-sided chest pain, worse with deep breath. “My breath feels short”. Denies fever, chills, cough, DOE, palps, trauma. Hysterectomy 3wks ago. Well yesterday, no other PMHx. Looks uncomfortable.

A

thoracic aortic dissection

71
Q

RF for thoracic aortic dissection

A

Marfan’s, Ehlers-Danlos, connective tissue dz, pregnancy, syphilis, family hx of sudden death at young age – all are risk factors

72
Q

classic symptoms for thoracic aortic dissection

A

sudden “tearing/ripping” w/ SOB, HTN. Jaw, neck, chest - pain evolves, changes.

Migrating pain above and below the diaphragm; GI complaints – n/v/d

Dizziness, near-syncope, neuro sx’s common (extremities can get weak)

73
Q

a. 40yo F c/o 4 hours of sharp, L-sided chest pain, worse with deep breath. “My breath feels short”. Denies fever, chills, cough, DOE, palps, trauma. Hysterectomy 3wks ago. Well yesterday, no other PMHx. Looks uncomfortable.
i. VS: 128/80, P 112, RR 20, T 99, O2 96% ra

A

PE

WELLS score is 6

74
Q

1 risk for PE

A

previous DVT/PT

75
Q

must consider a PE in everyone with

A

CP

76
Q

WELLS SCORE

A 
	Signs/Sx’s DVT - 3pts
	PE #1 Dx – 3pts
	Heart rate >100 - 1.5pts
	Immobilization 3 days or surgery <1mo - 1.5pts
	Hx proven PE/DVT-1.5pts
	Hemoptysis – 1pt
	Active malignancy – 1pt
77
Q

three tier and two tier model for WELLS

A

 Low prob = <2 pts (1.3%)
 Moderate = 2-6 pts (16.2%)
 High prob = >6 pts (37.5%)

 Two tier model
 “PE Unlikely” = 0-4 pts (12%)
 “PE Likely” = >4 pts (37%)

78
Q

criteria for PERC-ing a pt

do this for low risk

A

must answer YES to all of them

  • Age <50
  • Pulse <100
  • SaO2 >94%
  • No unilateral leg swelling
  • No hemoptysis
  • No recent trauma or surgery
  • No hx prior DVT or PE
  • No hormone use
79
Q

when do we do a D dimer

A

low to moderate risk that can’t be PERC out

80
Q

i. In every patient with chest pain, you must consider the “Big 6” – “cannot miss” diagnoses

A

(2 A’s, 3 P’s, a B)

ii. AMI/ACS/USA
iii. Thoracic aortic dissection
iv. Pericarditis/pericardial effusion
v. Pulmonary embolus
vi. Pneumothorax
vii. Boerhaave’s (espohageal
rupture/pneumomediastinum)

81
Q

clubbing is most commonly seen with

A

chronic bronchitis and people that have had surgery

Emergency Medicine (28 decks)

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