Pulmonary Emergencies Flashcards
Air way obstruction is most common in _________.
Children, children 1-3 yo are most susceptible. They more frequently place things in their mouths and lack molars for properly grinding their food. They are often running or playing at the time of aspiration.
What is the most common food item aspirated?
Peanuts
After foreign body aspiration where can the foreign body settle? Which place is the most common
The FB can settle into 3 anatomical sites, the larynx, trachea or bronchus. 80-90% of aspirated FBs become lodged in the bronchi (the right one being most common).
Where are larger foreign bodies more likely to be lodged?
The trachea or larynx
How do patients with laryngeal foreign bodies present?
Present with airway obstruction and hoarsness or aphonia
How do patients with tracheal foreign bodies present?
Present with coughing and can also demonstrate wheezing similar to asthma
How do patients with bronchial foreign bodies present?
Present with cough, unilateral wheezing and decreased breath sounds. Only 65% of patients have all 3.
Foreign body evaluation:
Two view CXR, findings that may be suggestive would be: unilateral hyperexpansion and lobar atelectasis or pneumonia
Suspected FB aspiration requires ____________. (Treatment)
bronchoscopic evaluation (aka: broncoscopy)
Angioedema is aka a _____________
Hypersensitivity reaction/allergic reaction
What are possible drug mediated hypersensitivity reactions?
ACE inhibitors and ASA
How do we treat angioedema?
Treat with antihistamines, steroids +/- epinephrine
What are the various etiologies of airway obstruction?
FB aspiration, Angioedema, Burns/Trauma, Mass (cancer) or Infectious (Croup, Epiglottitis and Peritonsillar Abscesses)
What are the symptoms of Croup?
Barking cough, stridor, prodromal URI symptoms
How do we treat Croup?
Single dose dexamethasone (PO or IM). Epinephrine indicated in moderate to severe cases.
____________ is the pathogen most commonly identified with epiglottitis. It causes a _____________ presentation.
H. influenza b; more severe
Lesser pathogens associated with epiglottitis:
Staph and Strep
What is the gold standard for the diagnosis of epiglottitis?
fiberoptic laryngoscopy
Besides the gold standard for diagnosis for epiglottitis, what are other diagnostic criteria?
lateral soft tissue neck x-rays are up to 90% sensitive.
Think thumbprint sign!
What is the treatment for epiglotittis?
Children are more likely to require airway protection, awake fiberoptic intubation is ideal.
Begin 3rd gen. cephalosporin + vancomycin or clindamycin
Who is more likely to develop a Retropharyngeal abscess?
Increasingly more common in adults.
What are the most common organisms associated with Retropharyngeal abscess?
Typically polymicrobial: anaerobes, Staph are most common flora
How does a patient with a Retropharyngeal abscess present?
Classically presents with sore throat, neck pain/stiffness, dysphagia and “hot-potato” voice
How do we diagnose a Retropharyngeal abscess?
On normal lateral soft tissue neck X-ray, soft tissue anterior to C1-C4 should be < 40% of the diameter of the adjacent vertebral body. Widening of this space suggests infection.
What is the treatment for a Retropharyngeal abscess?
Treatment is IV antibiotics and operative I and D
What is Ludwig’s Angina?
A progressive infection of the connective tissues of the floor of the mouth and neck which begins in the submandibular space.
What is the pathophysiology of Ludwig’s Angina?
Most commonly caused by infection originating in the area of the 2nd or 3rd molars
What is the patient presentation of Ludwig’s Angina?
Exam reveals bilateral submandibular swelling, elevation of the tongue, dysphonia
What is the treatment for Ludwig’s Angina?
Airway should be secured, preferably via fiberoptic guidance. Antibiotic coverage for oral flora, e.g. ampicillin-sulbactam, clindamycin.
How is a Peritonsillar Abscess diagnosed?
Diagnosed on the basis of infero-medial displacement of the infected tonsil with resulting uvular deviation. Needle aspiration confirms the diagnosis and is therapeutic.
Peritonsillar Abscess Treatment:
Larger abscesses may require I and D by ENT. Typical antibiotic coverage is amoxicillin/clavulanate, clindamycin also commonly utilized.
What is Aspiration pneumonitis?
Aspiration pneumonitis represents an acute, chemical lung injury resulting from the inhalation of gastric contents.
What is the pathophysiology of Aspiration pneumonitis?
It occurs when a patient inhales material from the oropharynx that is colonized by upper airway flora.
Diagnosing Aspiration pneumonitis:
Consider this diagnosis in patients with even transient alterations in level of consciousness resulting from dementia, delirium, seizures, CVAs, drug intoxication or head trauma.
Includes impairment of gag reflex, coughing, ciliary movement, and immune mechanisms, all of which aid in removing infectious material from the lower airways.
Who is most likely to develop Aspiration pneumonitis?
Most commonly occurs in individuals with chronically impaired airway defense mechanisms.
Causative organism of Aspiration pneumonitis:
Once thought to be primarily caused by anaerobic organisms but newer data suggests typical URI flora are more common
• S. pneumoniae
• S. aureus
• H. influenzae
Hospital-acquired cases are more likely to involve Staph, Pseudomonas
How is aspiration pneumonitis treated?
Prophylactic antibiotics generally not recommended in case of aspiration pneumonitis. No role for corticosteroids.
Treat aspiration pneumonia as you would pneumonia based on the setting it was contracted in (community vs. healthcare-associated).
In addition, anaerobic coverage is typically used to complement traditional pneumonia treatment.
What is Hyperventilation?
Not limited to tachypnea-may also refer to abnormally deep respirations.
What causes hyperventilation?
While anxiety is a very common cause of this presentation, must consider organic etiologies: • PE, along with other causes of hypoxemia • Pain • Acidemia (i.e. DKA) • Obstructive lung disease • Interstitial lung disease • Sepsis • Salicyclate overdose
How do we treat hyperventilation?
Treatment depends on underlying etiology. Consider administration of a benzodiazepine in the ED once organic illness excluded.
T/F: Pulmonary embolisms need to be diagnosed early. They are easy to diagnose but can be life threatening.
False, PE is traditionally difficult to diagnose. Missed diagnosis results in a large number of malpractice claims. Fear of missing the diagnosis results in frequent (negative) testing-with potential negative outcomes for patients.
PE triad:
Hypercoagulability, Stasis, Vessel injury
Risk Factors for a PE
Hypercoagulability, Venous Stasis, Venous Injury
What puts a person at risk for Hypercoagulability?
- Malignancy
- Nonmalignant thrombophilia: Pregnancy, Postpartum status (<~4wk), Estrogen/ OCP’s, or Genetic mutations (Factor V Leiden, Protein C & S deficiency, Factor VIII, prothrombin mutations, AT-III deficiency).
What puts a person at risk for Venous Stasis?
Bedridden status, Recent cast or external fixator and Long-distance travel
What puts a person at risk for Venous Injury?
Recent surgery requiring general anesthesia or Recent trauma (especially the lower extremities and pelvis).
Pathophysiology of a Pulmonary Embolism:
Venous emboli (typically from the lower extremities) may become dislodged from their site of origin, embolizing to the pulmonary arterial circulation or, paradoxically to the arterial circulation through a patent foramen ovale.
Pulmonary vascular resistance abruptly increases, causing increased RV wall tension and RV dilation and dysfunction
Elevated troponin and BNP predict mortality. Progressive right heart failure is the usual immediate cause of death from PE.
