Pulmonary and CP Flashcards
approach to pt with mild to moderate Asthma attack
3
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
Discharge
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
asthma pt can’t go home if
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
hallmark of asthma attack
bilateral!
if not–> another dz process
Other than wheezing what would we likely see in a pt with an asthma attack
Dyspnea, cough, chest “tightness”
Pronged expiratory phase, I:E ratio 1:3 or 4
Tachypnea, tachycardia, HYPOxia, HYPERcarbia
Poor peak expiratory flow measurements (PEFR)
how do you elicit a prolonged expiratory phase
blow out the cake with 100 candles
will hear prolonged exasperation
what is a nl peak flow
Poor peak expiratory flow measurements (PEFR)
650 or 700 is normal
why do we see asthma exacerbations most commonly in the ED
Med non-compliance, viral illness most common reasons
what other pts wheeze
CHF
PE
COPD
is the person is over 40 and does not have a dx of asthma WATCH OUT
essential questions for pts with asthma
have you had a fever?
have you had any trauma?
have you been sick?
have you had this before?
what is the neb treatment for asthma
albuterol neb 2.5 mg
once, 3x q20min or 10ml/1hr
COPD exacerbation will look like (VS)
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.
treatment goals for COPD
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
reasons for COPD exacerbations
- Disease progression
- Med non-compliance, out of home O2
- Infection - viral, bronchitis, pneumonia
- Cardiac - pump
failure/impairment, arrhythmia - Metabolic acidosis, other illness on top
- Exposure/environment
- Sedation, drugs
what do we see on a COPD CXR
Hyperexpanded lung fields, narrow cardiac silhouette, flat diaphragms, blunted costophrenic angles
what labs would you want in a COPD exacerbation pt
CXR, lung/cardiac US, EKG, monitor, labs
TX COPD
Continuous nebulizer treatments
Beta 2 agonists (10mg over 1h)
Inhaled anticholinergics
Oral steroids, IV if admit
Antibiotics if appropriate
Assisted ventilation - NIPPVantibiotic commonly used in COPD pts
doxy
they get the weird bugs
when can you NOT send a COPD pt home
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
presentation of pneumothorax
elevated RR
elevated pulse
94% Room air
sudden
focused Hx for pneumothorax
have you had this before?
cardiac and pulm ROS
PMH
trauma? syncope?
Pulmonary ROS
Cough? Sputum? Hemoptysis?
o Coughing up blood?
• Shortness of breath (SOB = dyspnea)? • Wheezing?
• Pleurisy?
Cardiac ROS
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
What do you do for suspected pneumothorax
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?
- Can deteriorate quickly
- Could be obstructive shock
v. Primary or Secondary? - Primary pneumo –> spontaneous
- Secondary pneumo —>a result of something
chest CT
surgery consult
Tx for pneumothorax
- Treatment depends on size
Pigtail catheter w/ Heimlich valve
Chest tube - Small, primary pneumos (<15% total lung) in select cases, a stable patient can go home if:
when can a pneumothorax go home
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
tension pneumothorax is dx
CLINCALLY
pt will die if not treated
Pt presentation of pneumothorax (5)
Pt with trauma to the chest
- Severe dyspnea, sudden change in VS/LOC
- *Decreased breath sounds affected side
- *Hypotension
- *Distended neck veins
- *Tracheal shift (late)
what is the Tx for tension pneumothorax
iv. Needle thoracentesis: 2nd ICS at MCL
with 16 gauge at second intercostal space mid-clavicular line
v. Follow with chest tube immediately
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
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
Pulmonary Effusion workup
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
if you have a pulmonary effusion you need to look for
pericardial effusion -triple scan
what can a CT tell us about a pulmonary effusion
- Excellent for small effusions, other dx’s
- CT guided thoracentesis if loculated – doesn’t layer out
- Effusions can be infectious, malignant, reactive, chronic, post-surgical, traumatic
TX for pleural effusion
- Sick? Is this shock? Fever?
- Triple scan US: fluid status, pericardial effusion
- 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 - Pleural fluid analysis
Thoracentesis for pleural effusion
diagnostic and therapeutic
who are you worried about in flu season
Young, old, immunocomp, recent surg/hosp, lung Dz
who gets a CXR with the flu
- Hypotension/tachy/tachy, hypoxic, lung findings
- No viral syndrome sx’s, worsening (We are worried about PNA)
sxs for more than 2 weeks
who get moved to maintain to the ED
Abnormal VS, chest pain, young/old, risks, look sick
Which Hx/PE findings really make a difference in a pt with suspected flu
- ROS: SOB, DOE, hemoptysis, leg edema/pain, syncope
- PMHx (cardiac, lung dz, DM, steroids), SH (etoh, homeless)
- VS, diaphoresis, new wheezes, rales, edema, rash
Who has the flu vs. who has pneumonia, other dx??
- Bacteria/pneumonia is very narrow minded and tends to stay in one spot
- Flu gives you symptoms all over – malaise, sore throat, fever, vomiting, maybe diarrhea (viruses affect a lot of different systems)
- CURB65
helps predict mortality in a person with pneumonia
CONFUSION BUN RR BP OVER 65
TX for pneumo
v. Abx:
Azithro mostly
Levo?, Doxy
MCC of hemoptysis
- Pneumonia = MCC
- Coumadin
- Tuberculosis
- Cancer
- Pulmonary embolus
- Hematemesis?
- Nasal, dental, oral source?
- Trauma
how does hemodynamically stable help us figure out hemoptysis
1:00hr
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)
what diagnostic tests should we be running for hemoptysis
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
f. HIV w/ infiltrates-what diagnostic tests would you want
CXR Labs: lactic acid LDH-helps predict severity cultures HIV labs: CD4 count, viral load
when is an HIV pt considered immunocompetent
- CD4 >200 = immunocompetent
i. Clinical Presentation of TB
Cough, fever, weight loss, fatigue, night sweats, pleuritic chest pain, dyspnea and hemoptysis.
Risks for TB
Classic sx’s, endemic area of origin - travel
Risks: immunocomp, incarcerated, known exposure, homeless, EtOH
- Lung exam in a pt w/ TB
can’t be diagnosed
variable
need CXR and labs
CXR presentations of TB
a. Infiltrates/consolidation
b. Reactivation favors upper lobes
c. Pleural effusion
d. Cavitary lesions
e. Calcifications
f. Miliary pattern
what do you do with TB in the ED
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
positive PPD hx with clean CXR and sxs of TB
ADMIT
+PPD, CXR, NO sxs
home
PCP or TB coordinator f/u and intiate tx
ED does not initiate tx
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
CHF AMI/ACS PE Pericardial effusion Infection Pleural effusion Renal failure Cancer
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
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 $$$$$
TX for CHF
- LMNOP-N
Lasixs Morphine NTG O2 Position NIPPV
- -Diuretics: Lasix
- -Vasodilators – NITRO IV reduce preload, afterload:
- Morphine +/-, Nitrates
- -Oxygen, Position
- -NIPPV is awesome
- -US better than BNP in ED unless Dx uncertain
- -Admit all new CHF – search for cause
- -Admit moderate, severe, recurrent, unstable
- B lines on lung U/S
how should we think about CHF
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
three questions we need for CHF
R or L or both
systolic or diastolic
high or low output failure
left sided Heart failure looks like
DOE cough fatigue orthopnea PND rales S3 gallop
right sided looks like
JVD
peripheral edema
hepatomegaly
anascara
systolic looks like
can’t squeeze enough
diastolic HF looks like
can’t relax to fill
low output failure
common chronic CHF low EF
high output failure
compensating for demand
thyroid storm
anemia etc
when do we NOT GIVE NITRO for CHF pt
right sided inferior MI viagra tamponade aortic stenosis or hypovolemia
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.
pulse a little high
RR pretty high
CXR–>good
Pulse OX–> good
get a Hgb 6.2 hct 20%
when do we see anemia sxs and what do they look like
when compensation fails
i. When compensation fails = Sx’s: DOE, dizzy, weak, malaise, palpitations, chest pain, syncope
tx for symptomatic anemia
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?
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.
thoracic aortic dissection
RF for thoracic aortic dissection
Marfan’s, Ehlers-Danlos, connective tissue dz, pregnancy, syphilis, family hx of sudden death at young age – all are risk factors
classic symptoms for thoracic aortic dissection
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)
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
PE
WELLS score is 6
1 risk for PE
previous DVT/PT
must consider a PE in everyone with
CP
WELLS SCORE
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
three tier and two tier model for WELLS
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%)
criteria for PERC-ing a pt
do this for low risk
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
when do we do a D dimer
low to moderate risk that can’t be PERC out
i. In every patient with chest pain, you must consider the “Big 6” – “cannot miss” diagnoses
(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)
clubbing is most commonly seen with
chronic bronchitis and people that have had surgery
