Pulmonary Emergencies Flashcards
Retropharyngeal Abscess
Emergency - extends from base of skill to tracheal bifurcation
Can spread to mediastinum
Children: usually from a lymph node that drains head and neck
Adults: penetrating trauma, mouth/teeth infection, or lymph nodes
Fever, neck pain, limitation of cervical motion, muffled voice, respiratory distress
CT scan of neck is gold-standard
Retropharyngeal Abscess Treatment
Immediate I&D
IV hydration
IV Clindamycin or Unasyn
GABHS, staph aureus, anaerobes, H-flu
Retropharyngeal Abscess Complications
Extension into mediastinum - pleural or pericardial effusion
Upper airway asphyxia
Sudden rupture - leads to aspiration pneumonia and widespread infection
Angioedema PEARLs
Often asymmetric swelling
Affects face, lips, mouth, larynx, extremities, genitalia, and bowel
Can occur in isolation, with urticaria, or as a part of anaphylaxis
Rapid assessment of airway, close monitoring, consider angioedema
Angioedema - Mast Cell Mediated
Responds to epi, glucocorticoid, and antihistamines
Allergic reaction
Intubate w/ any sign of respiratory distress
ACEI Induced Bradykinin Mediated Angioedema
Intubate immediately w/ sign of respiratory distress
DC ACEI - sx should resolve in 24-72 hours
Sx severe or no improvement in 24 hours - Antihistamines, C1 inhibitor therapy (recombinant C1 inhibitor)
Hereditary Angioedema
Intubate w/ respiratory distress
C1 inhibitor concentrate (Ruconest) - 1st line
Bradykinin receptor antagonist - 2nd line
Anaphylaxis
Acute, potentially lethal multisystem syndrome from sudden release of mast cells and basophils
Sudden onset urticaria, angioedema, flushing, pruritis, HOTN
Epinephrine is the only drug that will reverse the process
Can also give diphenhydramine, steroids, albuterol, vasopressors (shock)
Stridor - Inspiratory, Expiratory
Inspiratory: obstruction at the level of the larynx
Expiratory: obstruction at the level of the trachea
Stupor vs Coma
Stupor: lack of critical cognitive function and LOC - pt is almost entirely unresponsive, only responds to base stimuli like pain
Coma: unconsciousness lasting more than 6 hours - patient cannot be awakened, fails to respond to painful stimuli/light/sound, lacks normal sleep-wake cycle; no initiation of voluntary actions
Spontaneous Pneumothorax
Sudden onset of dyspnea, pleuritic chest pain that often occurs at rest
Decreased chest excursion, breath sounds; hyperresonant to percussion, possible subQ emphysema
Treatment: Supplemental O2, Needle decompression with chest tube placement
Tension Pneumothorax
Labored breathing
Tachycardia
HOTN
Tracheal shift
JVD
Acute Pulmonary Edema Presentation
Dyspnea
Frothy pink sputum
Pedal edema
Ascites
Rales/Wheezing
HTN
Hypoxemia
Tachycardia
Acute Pulmonary Edema
From cardiogenic and noncardiogenic sources
-Sudden increase in left-sided intracardiac filling pressures or increased alveolar-capillary membrane permeability
Acute Cause Cardiogenic Pulmonary Edema
Ischemia
Acute severe mitral regurgitation
Acute aortic regurgitation
HTN crisis secondary to bilateral renal artery stenosis
Stress induced cardiomyopathy
Chronic Causes Cardiogenic Pulmonary Edema
Decompensated systolic CHF
Decompensated diastolic CHF
Left ventricular outflow tract (LVOT) obstruction
Valvular heart disease
Causes Noncardiogenic Pulmonary Edema
Acute respiratory distress syndrome (ARDS) - Major cause
Altitude
Neurogenic
Narcotic overdose
Pulmonary embolism
Eclampsia
Transfusion-related injury
Salicylate overdose
ARDS Etiology
Sepsis
Acute Pulmonary Infection
Trauma
Inhaled toxins
DIC
Freebase cocaine smoking
Post CABG
Inhalation of high concentration O2
Cardiogenic and Noncardiogenic Acute Pulmonary Edema Treatment
Treat underlying cause, add on O2
Furosemide only in hemodynamically stable
Cardiogenic: Ischemia - nitrates, diuretics - also valvular disease; treat arrhythmias via ACLS protocols and diuretics
Noncardiogenic: ARDS - intubate w/ vent and PEEP; Diuretics may be helpful
Aspiration
Massive aspiration requires immediate protection of airway from further injury by intubation
Once intubated, can lavage and suction the lower airway
Treat underlying cause:
- prolonged BVM during CPR
- Neurologic compromise secondary to stroke/SAH/head injuries
Acute Asthma and Peak Flow
Allows an objective measurement of the severity of the airflow obstruction
Peak flow <40% predicted = severe airflow obstruction
Measure before and after each nebulizer or MDI treatment
Acute Asthma - Medical Therapy
Bronchodilator - albuterol (inhaled beta 2 agonist)
-Ipratropium bromide (Atrovent) - anticholinergic
Glucocorticoid - methylprednisolone
Magnesium sulfate - for life-threatening exacerbations that remain severe after 1 hour of intense bronchodilator therapy
Epi - for suspected anaphylaxis or unable to use bronchodilators
Terbutaline - for severe, unresponsive asthma; CANNOT GIVE WITH EPI
COPD Exacerbation
Most often viral or bacterial infection brings it on
Increase/change of usual symptom character - dyspnea, cough, sputum production
Admission - ADLs limited, fail to respond to initial therapy, high-risk comorbidities, worsening hypoxemia
-CURB-65
COPD Exacerbation Treatment
Supplemental O2
Solumedrol (methylprednisolone) 60 mg IV
Antibiotics - pseudomonas coverage - Levaquin
Inhaled bronchodilators - Albuterol and atrovent (Duoneb)
CURB-65
Confusion
BUN >7
Respiratory Rate >30
SBP <90; DBP <60
Age >65
Pulmonary Embolism
Dyspnea
Tachypnea
Cough with rales
Hemoptysis
Syncope
Lower extremity edema, pain, erythema
Cyanosis
Diaphoresis
HOTN
Pulmonary Embolism Radiographic Findings
Hampton’s Hump on CXR
CT with pulmonary infarction or saddle embolism
EKG: S-waves in lead 1; Q waves and inverted T waves in lead 3
-S1Q3T3
PE Treatment
O2
Stabilize HOTN - fluid bolus (500-1000 mL NS), vasopressors
Unfractionated heparin (in unstable) or LMWH (preferred)
Fondaparinux w/ allergy to heparin or Hx heparin-induced thrombocytopenia (HIT)
Start Warfarin
Thrombolytics w/ acute PE and HOTN w/ vasopressors or in hemodynamically unstable pts w/o high bleeding risk
Pneumonia Workup
Everyone gets PA and lateral CXR, CBC, CMP
Inpatient get blood cultures, sputum culture and gram stain, Pneumococcal and Legionella urine antibody tests
Pneumonia Admission Indications
SpO2<92%
Febrile >40 C
RR>30
Tachycardia >125
SBP <90
CURB-65
Pneumonia Severity Index (PSI/PORT)
Non-ICU Pneumonia Pathogens and Treatment
Strep pneumo MC
-RSV/Influenza, Mycoplasm, H-flu, Legionella, Chlamydia
Antibiotics: Respiratory fluoroquinolone (Levofloxacin), Antipneumococcal beta-lactam (Ceftriaxone), Macrolide (Azithromycin)
ICU Pneumonia Pathogens and Treatment
Strep pneumo
Legionella
Gram-negative bacilli
Staph aureus - consider MRSA
Antibiotics: Ceftriaxone + Azithro OR Cetriaxone + Levofloxacin OR Levofloxacin + Aztreonam
