Pulmonary Emergencies 1

Question 1

Upper Airway Obstructions caused by? (3)

Answer 1

1. Foreign Body
2. Tongue
3. Swelling/Oedema

Question 2

Upper Airway Obstruction assessment? (5)

Answer 2

1. Air Movement → stridor or snoring
2. Ability to talk and/or swallow → drooling, muffled voice
3. Associated SOB
4. Vital Signs needs to include an O² saturation
5. Is patient stable or unstable?

Question 3

Upper Airway Obstruction aetiology? (9)

Answer 3

1. foreign body
2. retropharyngeal abscess
3. angioedema
4. head and neck trauma
5. swelling/oedema from inhalation injuries
6. epiglottitis or croup
7. tonsillitis
8. peritonsillar abscess
9. ludwig’s angina (rare skin infection that occurs on the floor of the mouth, underneath the tongue - usually after a tooth abscess)

Question 4

1. If you hear noise coming out of the mouth or nose what kind of obstruction is it?
2. What should you do if there is complete obstruction of the upper airway?
3. What question should you ask/what should you prepare for?

Answer 4

1. Incomplete (stridor)
2. Heimlich + Magill Forceps
3. Do they need a Cricothyroidotomy?

Question 5

Retropharyngeal Abcess is a serious emergency

1. It can spread where?
2. Retropharyngeal space extends from where to where?

Answer 5

1. can spread to the mediastinum
2. the base of the skull to the tracheal bifurcation

Question 6

Retropharyngeal Abscess

1. Aetiology in children?
2. In adults? (3)

Answer 6

1. usually from a lymph node that drains the head and neck
2. penetrating trauma (chicken bones, etc) OR from an infection in the mouth/teeth OR lymph nodes that drain the head and neck

Question 7

What will you see on X-Ray for the Retropharyngeal Abscess?

Answer 7

Expansion of the Pre-Vertebral Soft Tissues

Question 8

What are the signs and symptoms of a Retropharyngeal Abscess? (11)

Answer 8

1. Fever
2. Dysphagia
3. Neck Pain
4. Limitation of Cervical Motion
5. Cervical Lymphadenopathy
6. Sore Throat
7. Poor ↓ Oral Intake
8. Muffled Voice
9. Respiratory Distress
10. Stridor (more likely in children)
11. Inflammatory Torticollis

Question 9

Work-Up for a Retropharyngeal Abscess? (2)

Answer 9

1. Lateral Soft Tissue X-Ray of the Neck during Inspiration
2. CT scan of the Neck is the ‘Gold Standard’

Question 10

Treatment of a Retropharyngeal Abscess? (3)

Answer 10

1. Immediate ENT consult
2. Treatment is surgical incision and drainage
3. IV hydration and IV antibiotics to be started in the emergency room

Question 11

Antiobiotic treatment of a Retropharyngeal Abscess? (2)

Answer 11

1. Clindamycin (adult dose 600-900 mg IV q 8 h)
   * OR*
2. Ampicillin-Sulbactam (unasyn - adult dose 1500-3000 mg q 6 h)

Question 12

What are the complications of a Retropharyngeal Abscess?

Answer 12

1. extension of the infection into the mediastinum → pleural or pericardial effusion
2. upper airway asphyxia
3. sudden rupture

Question 13

If there was a sudden rupture of the retropharngeal abcess what could happen?

Answer 13

1. aspiration pneumonia
2. widespread infection

Question 14

Angioedema

1. Swelling where? (2)
2. Swelling is described as? (2)
3. Can occur in association with? (3)

Answer 14

1. subdermal or submucosal swelling
2. swelling is diffuse and non-pitting
3. Can occur in isolation OR with urticaria OR component of anaphylaxis

Question 15

Angioedema Management? (2)

Answer 15

1. rapid initial assessment of airway and close monitoring
2. intubation or a surgical airway may be necessary

Question 16

Angioedema

1. affects where? (5)
2. often symmetric or asymmetric?

Answer 16

1. affects the face, lips, mouth, throat, larynx, extremities, genitalia and possibly the bowel (colicky abdominal pain)
2. often asymmetric swelling

Question 17

Angioedema Aetiology

1. Mast cell mediated responds to? 3 2. Bradykinin mediated is secondary to what? 2

Answer 17

1. Responds to -Epinephrine, -glucocorticoids and -antihistamines 2. Secondary to -ACE-inhibitors or -Hereditary angioedema

Question 18

Angioedema: Treatment (allergic) 4

Answer 18

1. Intubate immediately if any signs of respiratory distress Mast cell mediated (allergic): 2. epinephrine 0.3 mg IM 3. glucocorticoids (Methylprednisolone 60-80mg IV or oral prednisone 40mg) 4. diphenhydramine 25-50mg IV

Question 19

1. Angioedema: treatment ACE inhibitor induced? 2 2. If swelling is severe or no improvement in 24h? 3

Answer 19

1. -Intubate immediately if signs of respiratory distress -Discontinue the offending drug (ACEI). Usually symptoms resolve in 24 -72 hours. 2. -Antihistamines, -glucocorticoids (? Benefit) -C1 inhibitor therapy (recombinant C1 inhibitor obtained from the milk of transgenic rabbits or from donated blood/fresh frozen plasma

Question 20

Hereditary Angioedema: treatment 2

Answer 20

1. Intubate immediately if any signs of respiratory distress 2. Bradykinin receptor antagonist is second line therapy if C1 inhibitor concentrate not available from fresh frozen plasma or Ruconest.

Question 21

Define anaphylaxis?

Answer 21

Acute, potentially lethal, multisystem syndrome from the sudden release of mast cells and basophils into the circulation.

Question 22

Anaphylaxis: presentation 5

Answer 22

1. Sudden onset generalized urticaria (hives) (10-20% will have no skin symptoms) 2. Angioedema 3. Flushing 4. Pruritus 5 Hypotension

Question 23

1. Anaphylaxis: Treatment 2. Dosing?

Answer 23

1. Epinephrine. All other treatments are supportive and do not reverse the process. 2. Adults: 0.3-0.5 mg IM Children: 0.1 mg/kg with a max dose of 0.5 mg Give q 5-15 min up to 3 doses

Question 24

Anaphylaxis: Airway management 1. Immediate assessment for what? 2. Immediate intubation? 2 3. May require what?

Answer 24

1. Immediate assessment for -wheezing, -stridor and -difficulty breathing in general. 2. Immediate intubation if -marked stridor or -respiratory arrest. 3. May require a surgical airway.

Question 25

Anaphylaxis: Overview of treatment

Answer 25

1. Assess airway/do they need to be intubated? 2. Simultaneously give IM epinephrine and do everything else 3. O2 via nonrebreather (if they have a patent airway) 4. Need two large bore IV access sites 5. Normal saline rapid bolus via IV (1-2 L initially but may need more) 20 ml/kg in kids 6. Consider albuterol nebulizer, H1 blocker, H2 blocker, methylprednisolone

Question 26

Consider what supplemental medications with anaphylaxis? 4

Answer 26

1. albuterol nebulizer, 2. H1 blocker, 3. H2 blocker, 4. methylprednisolone

Question 27

Anaphylaxis: 1. Epi dose? 2. Which H1 blocker? 3. Which H2 blocker? 4. Wheich steriod? 5. Dose of nebulizer? 6. What for shock may be necessary?

Answer 27

1. Epinephrine 0.3-0.5 mg IM q 5-15 min X3 doses if needed 2. H1 blocker: diphenhydramine (Benadryl) 50mg IV 3. H2 blocker: ranitidine 50mg IV 4. Glucocorticoid: Solu-medrol 125mg IV 5. Albuterol nebulizer 2.5mg 6. Vasopressors for shock may be necessary

Question 28

Head and neck trauma: assessment What do the following sounds indicate? 1. Gurgling? 2. Snoring? 3. Stridor? 2 4. Wheezing?

Answer 28

1. Gurgling -Pooling of liquids in the oral cavity or hypopharynx 2. Snoring -Partial airway obstruction at the pharyngeal level from the tongue 3. Stridor -Inspiratory: obstruction at the level of the larynx -Expiratory: obstruction at the level of the trachea 4. Wheezing Narrowing of lower airways

Question 29

Head and neck trauma 1. Secure the airway while simultaneously protecting what? 2. What can often clear the airway? 3. When may need to displace the tongue forward to maintain a patent airway?

Answer 29

1. the brain and c-spine from further injury. 2. Jaw thrust maneuver and suctioning 3. Mandibular fractures

Question 30

Head and neck trauma: secure the airway 1. Avoid what with midface trauma to avoid communication with the cranium? 2. Rapid sequence intubation vs. intubation without paralytics How hard are they to adequately bag-valve mask ventilate? -Need to prep for what prior to RSI? -If hypopharynx is intact what will usually suffice for backup?

Answer 30

1. nasotracheal intubation 2. -crichothyroidotomy - LMA suffice for back up?

Question 31

Stupor and coma 1. Inability to protect airway due to what? 2. What are our options here?

Answer 31

1. lack of gag reflex 2. Oropharyngeal airway vs. intubation

Question 32

Define stupor? Define Coma?

Answer 32

1. Stupor is the lack of critical cognitive function and level of consciousness wherein a sufferer is almost entirely unresponsive and only responds to base stimuli such as pain. 2. Coma is a state of unconsciousness lasting more than six hours, in which a person: cannot be awakened; fails to respond normally to painful stimuli, light, or sound; lacks a normal sleep-wake cycle; and does not initiate voluntary actions.

Question 33

Pneumothorax 1. What is it? 2. Can occur how? 2

Answer 33

1. Accumulation of air in the pleural space 2. Can be spontaneous or trauma induced

Question 34

What is a spontaneous pneumothorax?

Answer 34

Pneumothorax that occurs without a precipitating event in a person without lung disease.

Question 35

Spontaneous pneumothorax Risk factors? 7

Answer 35

1. men 2. ages 20-40 3. thin build 4. smokers 5. family history 6. Marfan syndrome 7. prior episode has recurrence rate is 25-54%

Question 36

Spontaneous pneumothorax Presentation?

Answer 36

1. Sudden onset of dyspnea and pleuritic chest pain 2. Often occurs at rest

Question 37

Pneumothorax: Physical exam 5

Answer 37

1. Decreased chest excursion 2. Decreased breath sounds on the affected side 3. Hyperresonant to percussion 4. Possible subcutaneous emphysema 5. Hypoxemia

Question 38

Suspect a tension pneumothorax if? 5

Answer 38

1. Labored breathing 2. Tachycardia 3. Hypotension 4. Tracheal shift 5. JVD

Question 39

Pneumothorax: treatment 3

Answer 39

1. Supplemental O2 (before and after decompression) 2. Needle decompression followed by chest tube placement (unstable) 3. or primary treatment with chest tube Choice above depends on how stable the patient is

Question 40

Decompression of a pneumothorax is done where? 2

Answer 40

1. at the 2nd or 3rd ICS at the midclavicular line 2. at the 5th ICS at the anterior axillary line