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Emergency Medicine Clerkship > Pulmonary Emergencies > Flashcards

Pulmonary Emergencies Flashcards

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1
Q

Initial actions and primary survey in patients with respiratory distress?

A 
ABCs
Full set of vitals
O2 application via NC, non-rebreather, or BVM if patient requires assisted ventilations
IV access
Cardiac and pulse oximetry monitoring
EKG
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2
Q

Indications for non-invasive PPV?

A 
Moderate to severe dyspnea
Accessory muscle use
Paradoxical abdominal movement
Fatigue
RR>25
pH <7.35, pCO2>45
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3
Q

Contraindications for non-invasive PPV?

A 
Respiratory arrest/absent respiratory drive
Hemodynamic instability
Aspiration risk
Airway obstruction
Unable to tolerate mask
Mask does not fit
Altered mental status
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4
Q

Important history to gather in a patient with respiratory distress?

A 
Did the dyspnea begin suddenly? (If so, consider PE or spontaneous PT; if more gradual, consider COPD, pneumonia, or CHF)
Chronic or recurrent?
Positional or exertional?
Precipitating events?
Pertinent PMHx?
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5
Q

Important physical exam findings in a patient with respiratory distress?

A

Visible swelling in the upper airway (allergic reaction or angioedema)
Voice changes, stridor, drooling (ominous signs concerning for impending obstruction, can be related to infection, allergic reaction, or foreign body)
Focally absent or diminished breath sounds (consolidation, effusion, PT)
Wheezing (broncho-spasm)
Rales (pneumonia, PE, pleural effusions)
Unilateral leg swelling/tenderness
Signs of chest trauma (crepitus, bruising, tenderness)
Tripoding or use of accessory muscles

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6
Q

Additional tests in patients with respiratory distress?

A

EKG (ischemia, dysrhythmia, PE, pericarditis, pericardial effusion)
CXR (pneumonia, pleural effusions, pneumothorax, chest wall injuries)
Chest CTs (atypical infections, traumatic injuries, PE, aortic pathologies)
Bedside US (lungs, heart, lower extremities)
D-Dimer, BNP, serial enzymes

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7
Q

DDx for respiratory distress?

A 
Acute CHF exacerbation
ACS
Anaphylaxis
Asthma exacerbation
Cardiac tamponade
Non-cardiogenic pulmonary edema
PE
Pneumonia
PT
Upper airway obstruciton
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8
Q

Basic management for acute CHF exacerbation?

A

Nitrates
Diuretics
PPV

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9
Q

Basic management for ACS?

A

Aspirin
Antiplatelet/anticoagulant agents
Reperfusion

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10
Q

Basic management for anaphylaxis?

A

Epinephrine
Beta-agonists
Antihistamines
Steroids

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11
Q

Basic management for asthma exacerbation?

A

Beta-agonists

Steroids

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12
Q

Basic management for cardiac tamponade?

A

Pericardiocentesis

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13
Q

Basic management for non-cardiogenic pulmonary edema?

A

Supplemental O2
PPV
Diuretics

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14
Q

Basic management for PE?

A

Anticoagulation

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15
Q

Basic management for pneumonia?

A

ABX

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16
Q

Basic management for PT?

A

Needle decompression

Chest tube

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17
Q

Basic management for upper airway obstruction?

A

Early intubation for airway protection (cricothyrotomy as alternative), treat underlying cause

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18
Q

General definition of community acquired pneumonia?

A

Patient from the community or general population that do not have significant contact with the healthcare system

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19
Q

Typical and atypical pathogens seen in community acquired pneumonia?

A

Typical: Streptococcus pneumoniae, Haemophilus influenzae, Moraxella cattarhalis

Atypical: Mycoplasma pneumonia, Chlamydophila pneumonia, Legionella, and respiratory viruses

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20
Q

Single most common cause of CAP?

A

S. pneumoniae (25-50% of all infections)

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21
Q

Compare typical vs. atypical pathogens in terms of whether or not they are seen on gram stain and what can be used to treat them?

A

Typical - seen on gram stain, can be inhibited or killed using beta-lactam ABX

Atypical - cannot be visualized on gram stain and require special culture methods, not killed or inhibited by beta-lactam ABX

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22
Q

HCAP criteria?

A

Hospitalization for 2+ days in the preceding 90 days (not incubating at the time of admission)
Residence in a nursing home/facility
In the past 30 days: attendance at a hospital or hemodialysis clinic, home or clinic IV therapy (ABX and chemo), home wound care
Subtype - VAP develops >48-72 hours after intubation

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23
Q

Common pathogens causing HCAP?

A

Pseudomonas aerugonosa, Escherichia coli, Klebsiella pneumonia, Acinetobacter, Staphylococcus aureus

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24
Q

Signs and symptoms of pneumonia?

A

Fever, chills, productive cough, pleuritic pain, chest pain, dyspnea, malaise

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25
Q

DDx of pneumonia?

A

Bronchitis, viral URIs, influenza, PE, TB, pleural effusions, other cardiopulmonary patholgoies

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26
Q

Initial actions and primary survey in suspected pneumonia?

A

ABCs
-Airway: evaluate for stridor, edema, upper airway obstruction (reposition patient, place on non-rebreather and/or NC, airway maneuvers/adjuncts (head tilt/chin lift, jaw thrust, nasal trumpet insertion)

Breathing: assess for adequate ventilation; look for tachypnea, increased WOB, signs of respiratory distress (supplemental O2, non-invasive ventilation, ET intubation)

Circulation: assess perfusion of vital organs and identify signs of CV compromise from pneumonia causing sepsis or septic shock (if concern for sepsis -> 2 large-bore peripheral IVs, saline bolus of 30 cc/kg, early broad-spectrum ABX, possible central line/vasopressors)

Disability: assess mental status

Vitals
Peripheral access, monitoring, O2

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27
Q

True or false - historical features are helpful in distinguishing typical from atypical CAP.

A

False

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28
Q

Classical presentation of typical vs. atypical CAP

A

Typical: sudden onset of fever or chills, productive cough, pleuritic chest pain

Atypical: more protracted course beginning with upper respiratory symptoms, slowly worsening cough, malaise, fatigue

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29
Q

Classic finding of pneumonia 2/2 S. pneumoniae

A

Bloody or rust colored sputum

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30
Q

Classic finding of pneumonia 2/2 H. influenzae

A

Fever, muscle pain, fatigue

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31
Q

Classic finding of pneumonia 2/2 Mycoplasma pneumonia

A

“Walking pneumonia” - upper respiratory symptoms, gradually worsening over weeks or even months

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32
Q

Classic finding of pneumonia 2/2 chlamydophilia pneumonia

A

Pharyngitis, laryngitis, sinusitis, associated with outbreaks in close-contact settings

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33
Q

Classic finding of pneumonia 2/2 legionella

A

Respiratory + GI symptoms

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34
Q

Risk factors for HAP with S. aureus?

A 
Ventilator-dependence
IVDU
Immunocompromise
Recent influenza infection
Aspiration
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35
Q

Risk factors for HAP P. aeruginosa?

A

High-dose steroid use
Prolonged hospitalization or nursing home residence
Pre-existing lung disease

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36
Q

Distinguish aspiration pneumonia from aspiration pneumonitis.

A

Pneumonia: inhalation of oropharyngeal or gastric contents into the larynx or respiratory tract

Pneumonitis: chemical injury from inhalation of gastric contents due to regurgitation that can occur with drug OD, seizures, CVA, anesthesia

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37
Q

Risk factors for aspiration?

A

Dysphagia
Nursing home residents
Alcohol abuse

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38
Q

ABX for aspiration pneumonia?

A

Activity against GN -> 3rd generation cephalosporins, FQs, piperacillin

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39
Q

True or false - there are no individual or combination of clinical findings that rule in the diagnosis of pneumonia.

A

True

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40
Q

Dx pneumonia?

A

CXR

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41
Q

List # factors that predict pneumonia on CXR.

A

Temperature >37.8 C, tachycardia, absence of asthma, rales, locally decreased breath sounds on auscultation

42
Q

Pathogens of typical of lobar vs. multi-lobar vs. patchy infiltrates

A

Lobar - S. pneumoniae, K. pneumoniae

Multi-lobar - S. aureus, P. aeruginosa

Patchy infiltrates - Mycoplasma pneumonia, chlamydophila, legionella

43
Q

How might bedside US be used in the diagnosis of pneumonia?

A

Sensitivity of 86%, specificity of 89%, LR 7.8

44
Q

Gold standard for diagnosing pneumonia?

A

CT Chest (only use if CXR is equivocal or when other etiologies are suspected)

45
Q

In addition to CXR, what other diagnostic studies should be ordered in patients with suspected/confirmed pneumonia?

A

EKG, especially if tachycardic (patients with CHF, CT disease, severe sepsis/shock may develop cardiac ischemia and infarct 2/2 severe pnuemonia)

Blood Cx if requiring ICU admission or MV, septic patients, CAP + increased risk for bacteremia and resistant organisms

46
Q

Risk factors for CAP patients at increased risk of bacteremia and resistant organisms?

A 
Cavitary lesions
Leukopenia
Severe liver disease
Asplenia
Pleural effusions
Alcohol abuse
Severe CAP
47
Q

ABX options for CAP?

A

Macrolides
FQs
Doxycycline

48
Q

ABX options for HAP?

A 
Antipseudomonal beta-lactam
Pip-tazo
Imipenem, meropenem
Cefepime
Ceftazidime
Anti-MRSA agent
Vancomycin
Linezolid
49
Q

ABX options for aspiration?

A

Amp/sulbactam
Pip/tazo
Clinda + AG

50
Q

ABX for PCP?

A

Bactrim

51
Q

What ABX should be avoided in suspected TB, as it can increase resistance?

A

FQs

52
Q

ABX for chlamydophila?

A

Macrolides (first line)

Tetracyclines and FQs also effective

53
Q

Who needs admission for pneumonia?

A

Unable to tolerate PO ABX
Hypoxia
Sepsis
Respiratory distress

54
Q

Purpose of PSI (Pneumonia Severity Index)?

A

Validated risk stratification instrument for CAP; identify lower risk patients for outpatient treatment with PO ABX

55
Q

PSI categories?

A

Sex (M vs. F)
Demographics (Age, nursing home resident?)
Comorbid illnesses (cancer, liver disease, heart failure, CVD, renal disease)
PE findings (AMS, RR, BP, Temp, Pulse)
Lab and radiographic findings (arterial pH, BUN, sodium, glucose, Hct, PP arterial O2, pleural effusion)

56
Q

PSI scoring?

A

Sex - male (0) vs. female (-10)

Demographics - age (1 point for each year), nursing home (+10)

Comorbidities - neoplastic disease (+30), liver disease (+20), heart failure (+10), CVD (+10), renal disease (+10)

Exam findings - AMS (+20), RR 30+ (+20), systolic <90 (+20), temperature <35 or >40 (+15), Pulse 125+ (10)

Lab findings - arterial pH <7.35 (+30), BUN 30+ (+20), sodium <130 (+20), glucose 250+ (+10), Hct <30% (+10), PP O2 <60 or O2 saturation <90% (+10), pleural effusion (+10)

57
Q

PSI score interpretation

A 
Class I (0-50 points): 0.1% mortality
Class II (51-70 points): 0.6% mortality
Class III (71-90 points): 0.9% mortality
Class IV (91-130 points): 9.3%
Class V (131-395 points): 27.0%
58
Q

CURB-65?

A 
Confusion (+1)
BUN 20+ (+1)
RR 30+ (+1)
Systolic <90 or diastolic 60 or less (+1)
Age 65+ (+1)

0 or 1: mortality 0-2.6%
2 - possible OP management with close follow-up or short admission/observation
3: mortality 14%
4 or 5: mortality 27.8%

59
Q

Classic presentation of acute asthma?

A

Progressive (hours, days, weeks) symptoms of SOB
Non-productive cough
Wheezing in all lung fields
Chest tightness due to a decrease in expiratory airflow

60
Q

Most common trigger of acute asthma? Other triggers?

A

URTI; respiratory allergens, exercise, psychosocial stressors

61
Q

Initial actions and primary survey in a patient with suspected acute asthma?

A

Decide whether there is an immediate need for definitive airway management -> rapid sequence induction and intubation for patients in severe respiratory distress AND one of the following:

  • Albuterol or other medical therapies doo not reverse symptoms
  • Significant hypoxia even with supplemental O2
  • Too tired to continue breathing on their own

If not needed, do H&P while initiating treatment

62
Q

Initial treatment in acute asthma?

A

O2 required regardless of severity of breathing
Concurrent aerosolized beta-2 adrenergic bronchodilator through handheld or facemask nebulizer (O2 to 6-8 L/min, albuterol is 0.5% solution mixed with 2 mL of saline)
Monitor with continuous pulse ox (goal SpO2 >92%)
pIV if moderate to severe
If severe exacerbation not improving with aerosolized albuterol, give IM epinephrine 0.3-0.5 mg Q20 min (adults) up to 3 doses or subQ epinephrine 0.2 mg or terbutaline 0.25 mg
Oral or IV steroids if no initial response to albuterol or moderate to severe exacerbation

63
Q

Dx testing for acute asthma?

A

Not routinely indicated for acute exacerbation in known asthmatics

CBC if concern for underlying infection (limited usefulness because it can be elevated in acute asthma alone)

ABG only if hypoxic after initiation of supplemental O2

CXR if diagnosis is uncertain

EKG is not routinely helpful unless concern for other causes of symptoms

PFTs at bedside are the most useful objective test to aid in the treatment and disposition of a patient with acute asthma -> confirm cause of symptoms (obstructive lung disease), severity of exacerbation, monitor treatment response

64
Q

Define mild vs. moderate vs. severe exacerbations based on FEV1/PFTs.

A

Mild: >70% predicted/personal best of PEFR

Moderate: 40-69%

Severe: <40%

65
Q

Goals of Rx of acute asthma?

A

Correction of significant hypoxemia
Rapid reversal of airflow obstruction
Reduction of likelihood of relapse by intensifying therapy

66
Q

First-line therapy for acute asthma?
Methods of delivery?
Onset of action/duration of action?

A

Beta-2 adrenergic agonists
MDI or aerosolized via nebulizer
5 minutes
6 hours

67
Q

Administration of MDI vs. nebulizer?

A

MDI appropriate in mild to moderate exacerbations; as effective as neb

  • Use spacer
  • Albuterol two 90 mcg puffs into the spacer, repeat Q4-6 hours

Nebulizer

  • 0.5-1.0 mL (2.5-5.0 mg) of solution in 3 mL of saline
  • Q 20 minutes up to 3 doses
68
Q

Side effects of albuterol?

A

Tremor
Tachycardia
Mild hypokalemia

69
Q

How are anticholinergics used in acute asthma?

A

Ipratropium can be used in severe asthma or beta-blocker induced asthma
Evidence suggests that there is additional benefit when combined with albuterol (Duoneb or Combivent)

70
Q

What is the role of steroids in acute asthma?

A

Reduce airway inflammation
IV and PO have equal efficacy
Indicated in moderate to severe and in those who fail to respond to albuterol
Onset in 4-6 hours, but may take up to 24 hours to exert a significant clinical effect
Inhaled are used only for prevention (during Rx of asthma), not indicated during exacerbation

71
Q

Role of magnesium sulfate in acute asthma?

A

Beneficial in severe acute asthma

2 grams IV over 20 minutes

72
Q

Role of theophylline in acute asthma?

A

No role; no benefit when combined with beta-agonists, side effects include tremors, nausea, anxiety, arrhythmia

73
Q

What is Heliox and what is its role in acute asthma?

A

Helium-oxygen (80:20 or 70:30) mixture that may provide benefit with severe exacerbations

Helium is less dense than room air, allowing it to travel through narrow air passages in a more laminar fashion, increasing delivery of O2 or bronchodilators

74
Q

What determines dispo in acute anxiety?

A

Response to treatment over time measured by PEFR or FEV1 (goal -> obtain >70% predicted or personal best FEV1 or PEFR)

75
Q

Dispo for patients who require multiple nebs in the ED or who have a moderate to severe exacerbation that demonstrates a good response to ED Rx?

A

Discharge home with beta-2 agonists and steroids (short burst for 4-7 days or tapered dose over 10-14 days)

76
Q

Dispo for patients who have an incomplete response to therapy (40-69% predicted)?

A

Continued ED treatment until improvement

77
Q

Who gets admitted in acute asthma?

A

Poor response to treatment
Persistent severe symptoms
Persistent hypoxia (<90% sPO2) despite supplemental O2
PEFR or FEV1 <40%

78
Q

Classic presentation of COPD exacerbation?

A 
Wheezing
Productive cough
DOE
Chest congestion
Fatigue
Hypoxia
Tachycardia
Increased use of inhalers
Sputum change in color or quantity
New requirement of an upright sleeping position
Fever/chills
79
Q

Causes of an acute decompensation of a COPD patient

A 
Superimposed infection
Continued smoking
Non-compliance
Lack of usual medications or O2 therapy
Spontaneous PT
80
Q

Exam findings in COPD exacerbation?

A 
Pursed lip breathing
Cyanosis
Use of accessory muscles
Intercostal retractions
Barrel chest
Hyper-resonant chest
Wheezing/rhonchi/rales
Prolonged expiratory phase
Tachycardia
Tachypnea
Finger clubbing
Diminished or absent breath sounds
81
Q

Initial action and primary survey in a patient with COPD exacerbation?

A

ABCs
Vitals, monitor, continuous pulse ox, IV
Apply controlled O2 to all hypoxic patients (delivery system like Venturi mask or NC)
Avoid routine use of a non-rebreather mask with 15 L/min unless patient is not responding to lower flow rates -> in patients with chronic CO2 retention, high flow O2 may cause respiratory depression with rapid rise in O2 depressing the central ventilatory drive
Look for signs of respiratory distress/fatigue

82
Q

Work-up for COPD exacerbation?

A

Good H&P
CXR
Consider EKG, BNP, ABG, cardiac markers, D-Dimer if suspicious for another cause
Consider bedside US to look for pericardial effusion or PT

83
Q

Typical CXR findings in COPD?

A

Increased AP diameter
Flattening of the diaphragm
Decreased lung markings
Absence of another acute abnormality

84
Q

Common EKG features of COPD?

A

Low voltage, R-axis deviation
P pulmonale - peaked P waves in II, III, aVF
R atrial hypertrophy
Tachycardia
Multifocal atrial tachycardia (rare but specific to COPD)

85
Q

General treatment of COPD exacerbation?

A

Bronchodilators
Corticosteroids
ABX

86
Q

After O2, what is the initial treatment of choice in COPD exacerbation?

A

Bronchodilators (inhaled albuterol); no role for LABAs

Anti-cholinergic bronchodilators such as ipatropium bromide are also first line; Q4 hours

Combination therapy has not been shown to be superior but is frequently used

87
Q

Role of steroids in COPD exacerbation?

A

IV methylprednisolone or PO prednisone, typically 10-14 days with tapering doses (compared to 5 day pulse therapy in asthma exacerbation)

88
Q

Complications of steroids?

A

Worsening HTN
Elevated blood sugars
Gastritis
Psychosis

89
Q

Role of ABX in COPD exacerbation?

A

Used if signs of infection (fever, color change of sputum, increased volume of sputum) are present and in patients with moderate to severe exacerbations

Common options include macrolides, FQs, tetracyclines, and cephalosporins

90
Q

Adjunctive therapy for decompensated patients?

A

Continued respiratory decompensation with worsening CO2 retention and hypoxia despite standard treatment -> NPPV or ET intubation

91
Q

If rapid-sequence intubation is necessary, how should the ventilator be set?

A

TV 4-5 mL/kg of ideal body weight
Initial O2 flow: 50-100% depending on pulse ox and blood gas measurement
Initial mode - assist control with a fixed # ventilations

92
Q

General ventilator guidelines?

A

Correct acidosis
Correct hypoxia
Avoid high peak and plateau airway pressures by ongoing use of bronchodilators
Aggressive suctions of secretions
If peak pressure increase due to stacking phenomenon, disconnect the ETT and start with a more prolonged expiratory phase or decreasing the MV

93
Q

What happens in a pneumothorax and why can it be fatal?

A

Potential space between parietal and visceral pleura of the lung fills with air and collapses the lung; can be fatal if tension builds and pressure is placed on the vascular structures within the mediastinum

94
Q

Causes of spontaneous pneumothorax?

A

Frequently caused by a ruptured bleb
Primary -> no underlying disease, common in thin, young men with a history of tobacco use
Secondary -> underlying disease such as COPD, CF, lung cancer, and Marfan’s

95
Q

Classic presentation of spontaneous pneumothorax?

A

Sudden onset of sharp chest pain, often unilateral, with SOB that often increases over time, cough, pain more prominent in the back and shoulder, vitals may show tachycardia, tachypnea, hypoxia, and hypotension (depending on severity)

96
Q

Presentation of iatrogenic and traumatic PT?

A

Similar to spontaneous but with close proximity to trauma (penetrating and blunt) or invasive procedure (central line, thoracentesis, pacemaker, tracheostomy, biopsy)
Other causes include CPR and PPV

97
Q

Initial actions and primary survey

A

Consider, diagnose, and treat a tension pneumothorax
Classic findings -> hypotension, tracheal deviation away from side of injury, distended neck veins, respiratory distress/arrest, extreme difficulty bagging if intubated

If stable, ask about duration and onset of symptoms, hx of chronic diseases/prior presentation, recent procedures, traumas

Exam findings include unequal breath sounds, hyperresonance with percussion, decreased wall movement on affected side, palpate chest wall, note signs of trauma, vitals

CXR unless unstable/suspecting tension -> treatment

98
Q

CXR findings in PT

A

CXR (upright) -> linear delineation of the edge of the collapsed lung with no further lung markings beyond this line, tension will show shifting of mediastinal structures away from PT, subQ air, deep sulcus sign (anterior PT)

99
Q

Other Dx testing in PT?

A

CT scan - if stable, can be useful to quantify the size of PT and any underlying pathology or other injuries

US - very useful if upright CXR cannot be obtained

100
Q

Rx of PT?

A

Depends on severity; all patients get O2 and monitor

Tension - needle decompression with 14-gauge angiocatheter into 2nd ICS at midclavicular line, followed by chest tube

Large (>20%) - chest tube

Small - needle aspiration, small pigtail catheter, or simple observation with repeat CXR to assess for spontaneous resolution

101
Q

Dispo of PT?

A

Option of observing otherwise healthy patients with a small PT in the ED for 4 hours with repeat CXR

Majority will be admitted for further obs and management

Emergency Medicine Clerkship (18 decks)

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