Pulmonary Emergenices Flashcards
Respiratory Parameters to Know
Dyspnea = difficult to breath
Tachypnea = fast (20+) breathes/min
Hypoxia: spO2 < 90%
Acute Bronchitis
Etiology
Symptoms
Diagnosis
Treatment
Etiology
- inflammation in the large airways: cough without pneumonia, or chronic respiratory issues
- caused: VIRAL»_space; bacterial (adenovirus, influenzia, rhinovirus,etc.) (h.flu or s. pneumoniae)
- happens fall/winter
Symptoms
first phase = fevers, muscle aches viral/cold like symptoms
second phase = cough!!! persistant cough for 1-3 weeks
Diagnosis
clincal: history and symptoms
- can get CXR to rule out pneumonia
- ensure you can differentiate from pertussis! the whooping cough: can do PCR test & azithryomycin to treat
Treatment = supportive
- cough suppressant: guaifenesin
- wheeze? albuterol
- NO abx. (unless 10+ days with comorbities: Azithromycin)
- somtimes steroids
Pneumonia
Etiology
Symptoms
Diagnosis
Etiology
- infection of the alveoli usually due to aspiration of the pathogen
- or hematogenous spread: staph and strep
- most common cause of sepsis
- community acquired
- hospital acquired: infection after 48+ hours in hospital
- ventilator = after 48hours
- healthcare-assocaited = nursing home, etc. pts.
Risk Factors
- aspiration
- bacteremia
- debilitaion
- chronic disease, pulmonary disease
Symptoms
- cough
- fatigue
- fever
- dyspnea
- sputum
- chest pain pleuritic
- (URI symptoms usually first, then these)
Diagnosis
- clinical signs rails, consolidation, dull to percuss, rhonchi and wheezing
- Chest Xray- see infiltrates
- labs for WBC or sputum (not neede in ED)
Pneumonia: Pneumococcal
- elderly, under 2 or immunosuppressed
Symptoms
- bloody sputum
- rigors/fever
- dyspnea
- chest pain
CXR: lobar infiltrates
Pneumonia: Staph Aureus
who
- chornic lung disease
- aspiration risk pts.:nursing home
Symptoms
- insidious onset
- low-fever
- sputum
- dyspnea
CXR
- extensive disease
- empyema
- multiple infiltrates
- effusions
Pneumonia: Klebsiella
Who
-alcoholics
- eldery
- chornic lung disease
Symptoms
- acute onset:severe quick
- red current jelly sputum
- fever
- chest pain
CXR
- cavitations: necortotixing in lobar infiltrates
Pneumonia: Pseudomonas
Who
- generally hospital pt.
Symptoms
- they’re SUPER sick
- systemic illness
- confusion
- cyanosis
CXR
- bilateral lower lobe infiltrtaes
- +/- empyema
Pneumonia: H. flu
Who
- eldery
- immuncomp.
- sickle cell pt.
symptoms
- gradual onset
- sputum
- chest pain
CXR
- pleural effusions
- multilobal infiltrates
Pneumonia: Legionella
Who
- transplant pt.
Symptoms
- can get to ARDS/organ failure
- N/V/D
- sinusitis, myocardidis, pyleonephritis
CXR
- patchy infiltrtates
- hilar adenopathy
labs can confrim that is legionella but rarely done
Pneumonia: Treatment
Uncomplicated Outpatient
Uncomplicated Outpt.
first line = amoxicillin + macrolide
- amoxicillin + azyromycin
- amoxillin + clarithromycin
- amoxicillin + (doxycycline)
PCN allergy = 3rd gen ceph (cefpodoxime/cefditoren)
PCN allergy SEVERE = florquinolone (levofloxicin)
Pneumonia: Treatment
Complicated Outpatient or someont who had abx. in the last 3 months
first line : fluroquinolone
- levofloxacin
- moxifloxicin
or
Augmentin + azithromycin
Pneumonia: Treatment
Inpatient but not the ICU
first line = florquinolone (IV)
- levofloxacin
- moxifloxacin
or
ceftiaxone + azithrmycin
Pneumonia: Treatment
ICU
Multiple Drugs: by hospital
Ceftriaxone + Azirthromycin
or
Cefriaxone
Levofloxacin
Pneumonia: Treatment
Healthcare Associated
HC associated: think pseudmonas and MRSA coverage
3 drugs
cefepime + ciprofloxicin + vancomycin
Disposition fro teh ER: who stasy and who goes for pneumonia
Pneumonia
- most can go home
- clinical picutre to guide you
- CURB-65 and PSI good score tools to justify your need to admit
Aspiration Pneumonia
Etiology
Diagnosis
Treatment
Etiology
- inhaled oropharyngeal contents
- common in nursing home pt.
- common in those with impaired breathing or swallowing function
- causes a severe and acute pneumonitis
- posterior portion of the upper lobes and anterior portion of lower lobes affected
Diagnosis
- unilateral or patchy consolidation: RLL is most common
Treatment
- CAP: unasyn, augmentin, moxi or levofloxicin
- HAP: vanco or zosyn
- most need to be admitted
Acute Asthma
etiolgoy
symptoms
diagnosis in the ER
Etiology
- chronic inflammatory disorder: accumulation of inflammatory markers to teh airway vasoconstricts, thickens secretions and allows for edema to occur
Symptoms
- wheezing
- dyspnea
- cough
- sputum? fever? SOB? tight chest?
Diagnosis
- they probably alread have asthma dx.
- get their spO2
- if spO2 < 90 = get ABG
- get spirometry
- CXR if needed to rule out other things
Acute Asthma
Treatment
Dispo
Treatment
- ipatropium & albuterol nebulizer in the ED
- steroids: solumederol
need to ask
- if taken steroid before
- last dose? and how often?
if significant symptoms = discahrge them with prednisone burst x 5 days
Dispo
- depends on symptoms
- can observe or admit
- most go home
- refill Rx and make sure htey have F/U
what is Status Asthmaticus
Status Asthmaticus
- acute severe asthma attack that does NOT improve with bronchodilators or corticosteroids
Signs
- FEV 1 < 25% predicted
- ABG and spO2
- “youll know”
Treatment
- IV magnesium: 1-2 grams over 30 minutes
- CPAP/BIPAP
- intubate? use ketamine
- epinephrine only for refractory situations
sent to ICU
COPD
Etiology
Symptoms of the Exacerbation in the ER
Etiology
- chronic bronchitis and emphysema as as result of decreased airflow and alveolar abnormalities
- lost elastic recoli, naorrowing of airways occurs and collpase of smaller airways makes gas exchange difficult
- mucous statsis and bacterial colonization
- remember: FEv1/FVC < 0.7
Exacerations
- commonly URI triggered
- V/Q mismatch : more SOB than baseline
Symptoms
- chronic and progressive dyspnea
- cough
- sputum production
- cyanosis (blue bloater)
- tachypnea
- hypoxemia
- wheezing
- HTN
-
COPD
Diagnosis
Treatment
who goes to ICU
Diagnosis
- FEv1/FVC < 0.7 on spirometry + clinical symptoms
- ABG: respiratory acidosis (hold onto CO2)
- can get BNP, EKG and CRX to rule out others
Treatment
- adminster O2
- monitor on tele
- albuterol/ipratropium
- steroids: short term for the exacerbation
- can consider giving abx.
the ABG/SpO2 & PE will guide management
most go home: the older, sicker, comorb stay
ICU?
- severe dyspnea that need intubation or bipap
- AMS
- worsening hyoxpemia
- hemodynamic instable
Pneumothorax
Etiology
- free air in the potential space
- spontaneous or secondary from a lung disease
- smokers, males marfans syndrome (spont.)
- primary = ruputred bleb lets air into the apex
- secondary = visceral pleura is damaged
Symptoms
- tachycardia
- decreased breath sounds
- sudden onset dyspnea
- ipsilateral chest pain
- hyperresonant to percussion
- decreased tactile fremitus
if tension pneumothorax
- hypotension
- trachea deviates away
- severe dyspnea
- these pts. will look much sicker
PTX
diagnosis
treatment
Diagnosisi
- CXR: should be sufficient
- could get CT but CXR is good enough
Treatment
TENSION: immediate needle decompression and chest tubes (need decomp. in the 4th-5th ICS mid-axillary)
SPONTANEOUS: if first time & < 20% of the lung, normal VS: can observe 4 hours, repeat CXR and d/c with follow up
everyone else: consult surgery and clinically decide chest tube v. needle decomp.
stable pts. have normal VS, no hemothorax, and speak in full sentences
Pulmonary Embolism
Etiology
symptoms
signs
diagnosis
Etiology
- clot in the pulmonary arteries
- most are a result of a DVT
- deep VT > superfisical
- can be provoked:but most comonig into the ED are unprovoked
Symptoms
- unexplained dyspnea
- pleuritic chest pain
- pain increased by cough or breathing
- pulmonary infarct: severe pain in that one areas 1-3 days after the emboli event
Signs
- tachycardia
- tachypnea
- decreased O2
- mild fever
- some have normal VS = hard to dx.
- unilateral limb swelling and wheezing are you best clue because thats DVT + PE involvment
Diagnosis
- signs of hypoxemia or dyspnea with clear lung sounds on PE suggest a PE
then get…
Wells criteria (sick + comorb.)
PERC (for healthy pt.)
(remember S1Q3T3 on EKG is a sign)
hamptons hump and westermark sign on CXR
PE
DVT features to clue you in
tests to do
gold standard?
DVT Features
- unliateral LE pain, redness, swelling
- homans sign= not super reliable but its a thing
so now what
- US: can rule out a DVT
- D-Dimer; can exclude VTE
- chest CT anigo: will rule out PE
- V/Q: for your pregnant pt.
- gold standard: pulmonary angiography to get the PE
PE Treatment (but this is treatment for the DVT too)
STABLE and GOING HOME
- enoxaparin + coumadin
- or newer DOAC agents
- renal failure = have to us heparin (admit)
MODERATE to SEVERE (the PE is there od dx. use this or unstable)
- heparin, coumadin or enoxaprin
- admit to monitor them in coumadin prison (inpt.)
UNSTABLE
- surgical embolectomy or fibrinolysis (TPA)
Airway Obstruction
CONSCIOUS pt.
- ask them to cough
- do the heimlich
UNCONSCIOUS pt.
- do chest compression
- only remove FB if you can see it: no blind sweeps
- ventilate if you can
- CPR
ARDS
Etiology
berlin Criteria
Underlying Causes
Phases
Acute Respiratory Distress Syndrome
- severe dyspnea with rapid onset hyopxemia, diffuse pulmonary infiltrates and respiratory failure
- usually the result of a diffuse lung injury
- 100% of these pts. go to the ICU
Berlin Criteria
- onset within 1 week of clinical insult
- bilateral opacities on imaging not explained by lung/lobar collpar or nodes
- respiratory failure not due to cardiac failure or fluid overlaod
- PaO2/FiO2 ratio < 300 with PEEP > 5cm H20
Underlying Causes
- sepsis and bacterial pneumonia
- aspiration of gastric contents
- trauma
- drug OD
- too many trasnfusions (TRALI)
3 Phases
- Exudative: alvolar edema with lots of leukocytes
- Proliferative: inflammtion in the interstitium and early fibrosis of the lungs can start
- Fibrotic: 3 weeks after injur:y fiberotic changes & bullae formation or recovery
ARDS
Treatment Managment
Treatment
______________________________
Initiate volume/pressure limited ventilation: give lungs a break
- TV: < 6, pplat < 30
- RR < 35
Oxygenate
- FiO2 < 0.6
- SpO2 88-95%
Minimized acidosis
- pH > 7.3
- RR < 35
Diuresis (offload)
- MAP > 65
- dont overdiuresis and then hypoperfuse!
Endotracheal Tube Intubation
what is it
ET Tube: cornerstone of emergency airway management
- direct connection to the trachea allowinf for better oxygenation and ventilation
Key Tasks whild Intubating
- ensure ongoing cardiac rhythm monitoring is happening
- establish IV access and fluids
- try to normalize the pt. HR and BP and optimize their O2 prior to administering the sedating meds and starting
ET Intubation
Mallampati Classification
Class I: good airway
Class II - III: ehh
Class IV: difficult airway: hard to visualize the posterior structures
ET intubation
steps
Steps
- preoxygenate pt. = administer 100% O2 with 15 L/min for 3 minutes
Sizes of Et TUbes
8.0-8.5 = average adult man
7.5-8.0 - femlae adult
- clear oropharynx
- laryngoscope in left
- right hand to open mouth, operate and insert the ETT
- advnace and lift the blade into the oropharynx
- visualize and lift epiglottis
- see vocal cords
- advance ETT
- infalte ballon
- confirm placement
- secure tube with tape
what is rapid sequence intubation
RSI is the usuing of induction agent and NM blockade to faciliate a tube placement
- goal is to intubate with minimzing phsiologic perturbations
- superoir to sedation and allows high success rate of intubation
Meds to Use
- pre treat: lidocaine, fetanyl
- induction: etomidate, propfol, ketamine
- parlytic agenet (for gag) : rocuronium, vercuronium, succinylchoine
