Pulmonary/Chest Cases Flashcards
1
Q
Asthma in the ED
A
- Bilateral wheezing is the hallmark
- Dyspnea, cough, chest “tightness”
- Pronged expiratory phase, I:E ratio 1:3 or 4
- Tachypnea, tachycardia, hypoxia, hypercarbia
- Poor peak expiratory flow measurements (PEFR)
- Med non-compliance, viral illness most common reasons
- “All that wheezes isn’t asthma”
- New onset after 40yo is likely NOT asthma
- Correct the exacerbation: that is the goal
-You dont develop primary asthma after age 40
2
Q
Mild to moderate asthma exacerbations
A
- Hand held nebulizer – asap Albuterol 2.5mg in nebulizer:
- Once, x3 q20min or 10ml/1 hr
- 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…unless…
- Severe sx’s, fever, not improving, get worse or considering alternate Dx
-Albuterol nebulizer dosing: 2.5mg Albuterol (0.5ml of 0.5% diluted in 3ml normal saline)
-If shes a smoker or has COPD, you would consider Atrovent as well
-PREDNISONE IS KEY
-The HR will increase after the neb treatment – if the HR is now 160, THAT’S A PROBLEM
USUALLY NO NEED FOR LABS, CXR, ETC!!!
-If they have a fever, you need CXR
- Walk ‘em – while youre walking, you want to hear them speak. If they cant say a sentence without taking a breath, they cant go home!
- Most people do 60mg oral steroid
- B2 agonists can cause the lactic acid to rise
- If someone with asthma has ever been intubated,, that should scare you
- If they’ve ever had an exacerbation with a steroid burst, THEY CANNOT GO HOME!!
3
Q
When to discharge asthma exacerbations
A
- Walk ‘em, assure f/u, return precautions
- Rx’s: Oral steroid burst (60mg x5d or tapered dose Rx), inhaled steroid prescription
- Can’t go home if…
- Not responding to treatment, worsening
- Hypoxic - ambulatory pulse ox <94-95%
- PEFR not improved to 65-70% predicted
- ED visit in past 3 days for same
- Exacerbation during steroid burst
4
Q
COPD in the ED
A
- Exacerbations common, but why?
- 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
- Treatment goals – reverse hypoxia, reverse hypercarbia, restore effective ventilation
- Is this COPD or something else??
On CXR:
-Hyperexpanded lung fields, narrow
cardiac silhouette, flat diaphragms,
blunted costophrenic angles
- New arrhythmia with COPD exacerbation is NOT GOOD!!
- MUDPILERS – metabolic acidosis
5
Q
COPD diagnosis and tx
A
- IV, monitor, CXR, EKG, lung/cardiac US, labs (cbc, cmp, Utox, +/- troponin)
- Continuous nebulizer treatments
- Beta 2 agonists (10mg over 1h)
- Inhaled anticholinergics
- Oral steroids, IV if admit
- Antibiotics if appropriate
- NIPPV: Bipap – Bi-level positive airway pressure
- If no response to above tx
- Albuterol + Atrovent (Ipratropium) = DuoNeb– > 3mg Albuterol/0.5mg Ipratropium
- COPDers are often much older and sicker than asthmatics – don’t turn around as quickly as asthmatics
- IV O2 monitor
- Lung and cardiac US very important
- Beta 2 agonists, anticholinergics and steroids!
- Most of the time, people use doxy because these people often get weird pneumonias
-COPDers that fall asleep with RR of 40, THEY ARE HYPERCARBIC!!
6
Q
When should you NOT send home a COPD exacerbation
A
- Not responding, worsening symptoms/signs
- Mental status changes
- If require Bipap (usually)
- Hx recent severe exacerbations/intubation
- Older, co-morbidities
- New arrhythmia
- Uncertain of diagnosis
- Poor ambulatory pulse ox
- Poor home support
7
Q
pneumothorax
A
-IV, O2, monitor; EKG, tx pain
- CXR – search edges
- +/-Expir film, lateral decub; deep sulcus sign if in bed
- Bedside ultrasound
- Absence of “comet tailing”; the friction of pleural sliding
- Shock? Or stable now?
- Can deteriorate quickly
- Primary or Secondary?
- Chest CT
- Surgery consult
- Tall young males who have spontaneous pneumothorax
- What made you think this? He had a sudden onset, decreased pulse ox, increased RR
- Not thinking PNA or MI because hes 19
8
Q
Treatment of pneumothorax
A
- Treatment depends on size
- Pigtail catheter w/ Heimlich valve
- Chest tube
-Majority are admitted to Surgery
- Small, primary pneumos (<15% total lung) in select cases, a stable patient can go home if:
- Not a secondary pneumo
- Stable vitals after 3-4hrs
- Repeat CXR with no enlargement
- Pt is reliably able to return in 12-24hrs for repeat CXR
- If catheter re-expansion (Stable x6hrs)
- Surgical consult agrees
9
Q
Tension pneumothorax
A
- Air into pleural space - one-way valve
- Rare, deadly: seconds count
- Clinical diagnosis - often post-trauma
- Severe dyspnea, sudden change in VS/LOC
- *Decreased breath sounds affected side
- *Hypotension
- *Distended neck veins
- *Tracheal shift
- Needle thoracentesis: 2nd ICS at MCL
- Follow with chest tube immediately
- This is a CLINICAL diagnosis!! NOT AN XRAY DIAGNOSIS
- This person will die if you don’t treat it!!
- Usually a 16 gauge that you can find – 2nd intercostal space at the mid clavicular line
10
Q
Pulmonary effusion
A
- IV, O2, monitor, pain control, labs
- CXR; Lateral decubitus film – does it layer out?
- Bedside ultrasound - see fluid, guides tap – also check for pericardial effusion
- Chest CT - gold standard
- 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
- If you get a pleural effusion, you as the practitioner need to check for pericardial effusion!!
11
Q
pulmonary effusion treatment
A
- 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
12
Q
The flu red flags
A
- Who should you be worried about?
- Young, old, immunocomp, recent surg/hosp, lung Dz
-Who gets a CXR
- Hypotension/tachy/tachy/fever, hypoxic, lung findings
- **No viral syndrome sx’s, worsening, sx’s >2wks
- Who gets moved to the main ED?
- Abnormal VS, chest pain, young/old, risks, look sick
- Which Hx/PE findings really make a difference?
- ROS: SOB, DOE, hemoptysis, leg edema/pain, syncope
- PMHx (cardiac, lung dz, DM, steroids), SH (etoh, home)
- VS, diaphoresis, new wheezes, rales, edema, rash
-Who has the flu vs. who has pneumonia, other dx??
- Tachy tachy = tachycardic and tachypnic
- Bacteria, PNA are different – cough (sore throat), no n/v, no diarrhea
- If you don’t have viral sxs (runny nose, upset stomache, n/v, diarrhea, etc.)
13
Q
pneumonia
A
- Common: sick or not sick? Know Sx’s/Red Flags/Risks
- CXR for Dx
- If +/- sick, risks: lactic acid for sepsis; labs, CURB65
- Admit sick; D/C not sick w/ close f/u, return precautions
- Abx: Azithro, Levo?, Doxy
- If D/C: educate, sx relief
- 100 CXR’s…
- CURB65 – clinical decision score to determine 30 day mortality risk in patients with pneumonia.
- Points for confusion, BUN, respiratory rate, blood pressure, age >65
- Higher the score, greater risk for 30 day mortality. Indication for admission
- PNA is a big cause of sepsis so you need to recognize it!
14
Q
Hemoptysis
A
- Pulmonary or non-pulmonary?
- Amount in 24hrs? Small amounts common
- Hemodynamically stable?
- Common causes:
- Pneumonia
- Coumadin/thinners
- Tuberculosis
- Cancer
- Pulmonary embolus
- Hematemesis?
- Nasal, dental, oral source?
- Trauma
- ABC’s, vitals; IV(s), O2, monitor
- Hx: Onset? Chest pain? SOB? Weight loss? Fever? Trauma? Coumadin/thinners? CAM?
- PE: Usual suspects + look for non-pulmonary source
- CXR, EKG, Labs, lactic acid, PT/INR. Type and screen/cross?
- Chest CT if significant
- If very significant, ongoing: a big airway concern. Make a plan
- Pulmonary consult: bronchoscopy
- Admit: significant or bad dx
- Hemodynamically stable = appropriate BP and nomal HR
- If hemoptysis is significant, you need a chest CT to find out why
15
Q
HIV with infitrates
A
- IV, O2, monitor
- CXR, labs, lactic acid, LDH, cultures, HIV labs: CD4 count, viral load
- CD4 >200 = immunocompetent
- Need isolation? Reverse Isolation? TB concern? Mask
- Tx common and special pathogens
- Rapid initiation of IV Abx
- Monitor LOC, respiratory effort
- Admit all immunocompromised pt’s if febrile and/or hypoxic
- LDH is very important for AIDS pts
- Note their respiratory effort
16
Q
Tuberculosis clinical presentation
A
- Classic: Cough, fever, weight loss, fatigue, night sweats, pleuritic chest pain, dyspnea and hemoptysis.
- High index of suspicion
- Classic sx’s, endemic area of origin - travel
- Risks: immunocomp, incarcerated, known exposure, homeless, EtOH
- Lung exam variable
- Hx +PPD – reactivation TB
- Multi-drug resistance
- If respiratory distress - are very sick
17
Q
Tuberculosis ED diagnostics
A
- Mask, isolation precautions asap
- Chest Xray asap
- Infiltrates/consolidation
- Reactivation favors upper lobes
- Pleural effusion
- Cavitary lesions
- Calcifications
- Miliary pattern
- PPD?
- Sputum for AFB, culture
- Quantiferon Gold - an aid for detecting latent Mycobacterium tuberculosis infection. It measures a component of cell-mediated immune reactivity to M. tuberculosis. The test is based on the quantification of interferon-gamma (IFN-) released from sensitized lymphocytes in whole blood incubated overnight with purified protein derivative (PPD) from M. tuberculosis and control antigens.
- Result is not affected by prior BCG
18
Q
TB disposition in the ED
A
- Suspected TB in respiratory distress = admit
- High risk, classic symptoms, CXR with any infiltrate or effusion = you are done – admit
- Positive PPD hx, CXR neg, classic symptoms = admit
- Unknown PPD + risk + sx’s + neg CXR = place PPD, get Quantiferon Gold, admit if sick, close f/u if not sick
- Positive PPD, CXR neg, no sx’s = home, PCP or TB coordinator f/u to initiate treatment
- ED rarely initiates outpatient treatment
- Outpatient TB treatment is complicated. Must identify appropriate drug, requires monitoring (compliance and LFT’s). ED not suited for this level of follow-up.
- Classic sxs: cough, night sweats, weight loss, hemoptysis
19
Q
Differential Diagnosis for Breathlessness, chest tightness, pale, anxious, uncomfortable
A
- CHF
- AMI/ACS
- PE
- Pericardial effusion
- Infection
- Pleural effusion
- Renal failure
- Cancer
- Begin with: IV, O2, monitor, EKG, CXR, Triple scan ULS (then formal)
- CBC, CMP, lactic acid, troponin, UA, Tox screen
- Solid Hx & PE when more stable
- **BNP: $$, positive in PE/COPD too.
- Order when Dx unclear, no ULS available
20
Q
Cardiogenic pulmonary edema
A
-CHF is a simplified term for a more complex problem
-Structural or functional inability of ventricles to fill and pump blood effectively:
-Acute (less common, emergent) vs. Chronic (common, familiar, recurrent)
Acute: ”flash” pulmonary edema; L-sided – MI, HTN emergency, valve rupture, etc
-Chronic: HTN, valve Dz, CAD -> cardiomegaly, mitral regurg, aortic stenosis, etc
-Think: Left or Right-sided (or both) failure? Systolic or Diastolic failure?
-Low or High output failure?
Left sided: left ventricle fails to pump blood out effectively (Sx’s: DOE, cough, fatigue, orthopnea, PND, rales, S3 gallop.)
-Right sided: usually result of left sided failure (Sx’s: JVD, peripheral edema, hepatomegaly, anasarca)
-Systolic: ventricle can’t “squeeze” enough to empty contents. Low EF, common
-Diastolic: “Squeeze” ok but ventricle can’t “relax” to fill during diastole
-Low output: common, chronic CHF. Low EF
-High output: compensating for demand: thyroid storm, anemia, etc
- Symptoms mimic several entities – keep a broad DDx!!
- Flash pulmonary edema – result of sudden rise in left-sided filling pressures
21
Q
CHF tx
A
- Reduce preload, afterload with Vasodilators -> Nitroglycerin
- IV (100mics), sublingual (0.4mg = 400mics!) waiting for drip
- **No NTG if RV/inferior MI, Viagra, tamponade, aortic stenosis, hypovolemia
- Diuretics IF volume overload: Lasix is first choice (US the IVC)
- NIPPV is first line tx, if sick
- Oxygen, Positioning
- Admit all new CHF – search for cause – this is key!
- Admit moderate, severe, recurrent or unstable CHF
BNP is expensive (>$200 in our ED)
- Nitro contraindicated if RV infarct/inferior wall MI, Viagra, aortic stenosis, pericardial tamponade. May start lower than 100mics – often tx with 200mics or more
- Morphine is weak vasodilator and sometimes indicated/helpful
-Isolated diastolic dysfunction is not common and is complex and difficult to manage. Consult the intensivist/ICU team for recommendations
22
Q
Symptomatic Anemia
A
- Anemia is often chronic, well compensated:
- Increase cardiac output (HR) for O2 delivery to tissues when needed.
- When compensation fails = Sx’s: DOE, dizzy, weak, malaise, palpitations, chest pain, syncope
- Transfusion is treatment
- Not benign! It’s not the numbers. It’s the sx’s, effects of low Hgb
- Risks: transfusion Rx, infection, hyperkalemia
- Type/screen, type/cross for packed red blood cells (units)
- So…why is this patient anemic?? Melena? Menstrual? Cancer? Renal Failure? Iron? Macro- or Microcytic?
23
Q
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
- Classic: sudden “tearing/ripping” w/ SOB, HTN. Jaw, neck, chest - pain evolves, changes. Rarely classic presentation….
- Migrating pain above and below the diaphragm; GI complaints – n/v/d
- Dizziness, near-syncope, neuro sx’s common
- If sx’s present, consider this Dx – it is elusive
- Document risk factors - you thought of it
- CT chest w/ contrast, Transesophageal echo
- Young patients with SOB, chest discomfort can be sick too!
- Ehlers-Danlos syndrome: inherited connective tissue disease, 13 subtypes, incurable. Features: hypermobile joints; stretchy, “velvety”, fragile skin that bruises easily; vascular fragility/rupture
- Syphilis can cause this!!!
- Ripping in my chest -> SCAN IMMEDIATELY!!
- Radiation to the back -> think aorta!!
24
Q
Venous thromboembolism
A
- Deep Venous Thrombosis (DVT) & Pulmonary embolus (PE)
- DVT: Unilateral leg pain, edema, warmth (leg most common)
- PE: Clot has travelled to the pulmonary vasculature
- Risk: Virchow’s Triad (1856)
- Venous Stasis: LE cast, hospital stay, bedridden, travel, paralysis
- Hypercoagulability: previous DVT/PE (#1 risk), malignancy, increased estrogen, coagulation dz, inflammatory (Pregnancy; hormone BC; Factor V Leiden, Protein S, C or antithrombin III deficient, lupus, sickle cell, vasculitis)
- Endothelial damage: recent surgery (<3mos), trauma, indwelling venous catheter, IVDU
- PE is a complication of DVT
- Risk factors for DVT same as for PE
- ER is the one that diagnoses this!
- Rare to have primary clot ONLY in your chest
- NUMBER ONE RISK IS PREVIOUS DVT OR PE
25
Q
Pulmonary embolism
A
- 650,000 diagnosed in US/year; 400,000 missed dx; 30% dx’d at autopsy
- 3rd leading cause death in hospitalized pt’s
- Ventilation-perfusion mismatch: no perfusion = no diffusion
- Right heart outflow impeded -> reduction in left ventricular preload -> refractory hypotension -> shock -> death
- Massive PE: dramatic presentation
- Submassive/segmental PE: everyone else – this is our challenge
26
Q
When do you suspect a PE
A
- Consider PE in everyone w/ chest pain or…classic presentation:
- Sudden/rapid, unexplained dyspnea
- Pleuritic chest pain, resting tachycardia
- Cough, usu non-productive, maybe hemoptysis
- Lower extremity pain, swelling with above symptoms
- Lung, cardiac, extremity exam is often normal
- Resting, persistent tachycardia (>100)***
- Resting, persistent tachypnea (>20min)***
- Low grade temp maybe, but <102
- O2 saturation may be normal: normal O2 sat does not R/O PE
- Chest wall +/- tender - reproduces pleuritic pain
- Anxiety - 50% with PE have it. Hyperventilation???
27
Q
PE on the ddx
A
- Work up is tricky, extensive, radiation (chest CT w/ contrast)
- Assess pt’s risk for PE: begin with Hx (Virchow’s Triad), PE, DDx
- Determine a “pre-test probability” – your clinical gestalt plus a clinical prediction tool
- “Pre-test probability”: Low, Moderate or High
- Assign score prior to testing to help determine the probability & likelihood for Dz = “risk stratify” the pt
- Problem: 20% of patients with a proven PE had NO risk factors
- Lack of risk factors alone does not rule out a PE
- Lack of risk factors affects your pre-test probability only
- Chest CT w/ contrast PE protocol (contrast timed, thin cuts 0.3mm) is the Gold Standard test for PE
28
Q
Well’s Criteria for PE
A
- Assign a 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 model:
- 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%)
29
Q
PERC score - the LOW RISK PATIENT
A
- PE rule-out criteria
- MUST have LOW Risk and Pre-test Probability to even use this tool!
- MUST answer YES to all questions: 1pt each
- Score must be 8 or cannot “PERC ‘em out”
- In “Low Risk” patient - <2% PE - if all true
- Document PERC score
- 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
30
Q
Can’t use the PERC criteria?
A
- Low to Moderate risk pt (Well’s <4) that you can’t “PERC out”
- You already have a Low to Moderate pre-test probability
- The patient’s Well’s score for PE is 4 or less
- PE is “unlikely” (two tier method)
- Order a D-dimer
- If the D-dimer is normal: 98% had no PE in this study
- If the D-dimer is positive (>500): You now have to test for a PE
- Chest CT w/ contrast, PE protocol
- The Christopher Study
31
Q
ED work-up of PE
A
- Chest Xray - often non-specific
- Hamptom’s hump, Westermark’s sign (both late findings)
- EKG - often non-specific, sinus tach, S1Q3T3 in 15%
- Labs, lactic acid, PT/INR
- D-Dimer – low-moderate risk and low pre-test probability patients only
- Bedside ULS and/or formal doppler ULS for DVT; bedside echo for right heart strain, “D” sign
- Treatment if PE present:
- Low-molecular weight heparin*
- Admit
- Stool guaiac before treatment!
- Heparin also acceptable. Some new anticoagulants being considered as first line treatment for PE
Echo with Right Heart Strain: RA & RV enlargement; “bowing” of R ventricle – the “D” sign – highly suggestive
32
Q
PE summary - ED decision making
A
- Low risk and low PTP? PERC score 8? <2% have PE
- Low Risk/PTP but can’t PERC ‘em out?
- D-dimer
- Lower extremity doppler ultrasound for DVT
- If both negative – done – unlikely PE
- “Practitioner gestalt” – valuable (but takes experience)
- Moderate (Well’s >4) to High Risk and high PTP?
- Must perform testing for PE
- D-dimer not useful in these patients – do not order it!
- Ultrasound bilat lower extremities for DVT, echo for RV strain, “D” sign
- Chest CT with contrast, PE protocol – Gold Standard test
- Consider VQ scan: if can’t CT, allergy to contrast, new ARF (creat >2)
- MRI may be a possibility in some centers
- PPT = pre-test probability
- Practitioner gestalt is still more valuable than a D-dimer
33
Q
the big 6
A
- In every patient with chest pain, you must consider the “Big 6” – “cannot miss” diagnoses (2 A’s, 3 P’s, a B)
- Your chart, presentation and DDx should address all of these in any patient with chest pain
- AMI/ACS/USA - AMI/ACS/USA = Acute Myocardial Infarction/Acute Coronary Syndrome/Unstable Angina
- Thoracic aortic dissection
- Pericarditis/pericardial effusion
- Pulmonary embolus
- Pneumothorax
- Boerhaave’s (espohageal rupture/pneumomediastinum)
