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
