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R9 - Emergency Medicine > Pulmonology > Flashcards

Pulmonology Flashcards

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1
Q

acute brionchiolitis etiology, RF, sxs

A
  • nonspecific inflamm injury that affects the lower resp tract
  • pathogen: RSV (MCC in children, late fall/winter), rhinovirus (spring, fall), parainfluenza type 3 (early spring, fall)
    • mostly fall/winter <2yo
  • RF: premature, low birth weight, age <12wk, CHD, CLD, immunodeficient, severe neuromuscular dz
  • sxs: preceding 1-3d URI (nasal congest, dc, cough), low fever, resp distress or SOB (insidious onset), dry cough, rhinorrhea, irritability, feeding difficulty
  • signs: end-insp crackles, high-pitched insp wheezing, prolonged exp phase, tachycard, tachypnea, hyperresonant, cyanosis/pallor, hypoxemia, retractions, nasal flaring, grunting, sunken fontabelle, low UOP in kids
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2
Q

acute bronchiolitis dx and tx

A
  • dx: mainly clinical dx, CXR (not require, but shows hyperinflation and interstitial infiltrates, peribronchial thickening, PCR confirms dx, RAT for RSV or other viruses
  • tx: self-limited, O2 (nasal canula), IVF, PO or NG feedings
  • prophylaxis: palivizumab
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3
Q

management of brionchiolitis by severity

A
  • nonsevere (O2 >93%, no apnea, minimal accessory m use, tx at home): supportive care, anticipatory guidance (suction nose, monitor fluid intake and output, FU with PCP), antibiotics for otherwise healthy infants
  • severe: requires treatment in ER, ICU, or inpatient setting - bronchodilator, nebulized hypertonic saline or roids
  • when to admit: toxic appearance, poor feeding, lethargy, dehydration, mod/severe resp distress, apnea, hypoxemia +/- hypercapnia, parents unable to care for child at home
  • prophylaxis: hand hygiene, palivizumab, annual flu vax
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4
Q

Croup (laryngotracheobronchitis)

A
  • 6mo-3y, fall or early winter, M>F
  • MC pathogen: parainflu 1, 2, or 3 (2 milder than 1, 3 = sporadic and severe
  • sxs: URI prodrome (nasal dc, congestion, coryza), gradual onset, progresses over 12-48h, low fever, seal-like barking cough (resolves in 3d), hoarseness
  • signs: insp stridor, subcostal retractions
  • dx: AP x-ray of neck = steeple sign
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5
Q

mild, moderate, and severe croup

A
  • Mild: no stridor at rest (may be present with crying or upset), barking cough, hoarse cry, mild to no chest wall or subcostal retractions
    • tx: supportive care (humidifier or cool mist, antipyretics, oral fluids), AND single dose of PO dex OR nonpharm management
  • moderate: stridor at rest, mild retractions, other sxs/signs of resp distress, no agitation
  • severe: significant stridor at rest, severe retractions (indrawing of sternum), anxious, agitated, or pale and fatigued child
    • moderate and severe tx: supportive care (anxiety can worsen airway obstruction, humidified air or O2, antipyretics, PO intake, instruct parent to hold or comfort child as anxiety can worsen airway obstruction), dex, racemic epi (can be repeated q15-20min), or L-epi
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6
Q

respiratory syncytial virus etiology, RF, sxs

A
  • paramyxoviridae fam, single-stranded, RNA, highest incidence in infants 1-6mo, peak in jan/feb
  • transmission: inoc of nasopharyngeal or ocular mucosa, fomites, direct contact
  • RF: infants <6mo, underlying CLD, premature, CHD, down syndrome, imunocompromised, asthma, high altitude, adult with cardiopulm dz or COPD
  • sxs infants/children: LRTI/bronchiolitis, PNA, apnea, wheezing, hyponat dt SIADH
  • sxs adults: URI or tracheobronchitis, wheezing, SOB, URI
  • general sxs: rhinorrhea, low-grade fe er, mild systemic sxs, cough, wheezing, dyspnea
  • signs: tachypnea, weheezing, rales, rhonchi
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7
Q

RSV dx and tx

A
  • dx: CLINICAL, CXR (diffuse infiltrates), sputum cx or throat swab (PCR), BAL
  • tx: supportive care, hand washing, most recover gradually over 1-2wks
    • neb ribavirin (nucleoside analog, reservved for immunocompromised pts with severe illness, recommended in adults with stem cell transplant, CI in preg)
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8
Q

MC PNA pathogens by age group and txs

A
  • neonates (<1mo): E. coli, GBS, S. aureus, Listeria, C. trachomatis
    • tx: amp + gent or amp + cefotaxime
  • 2w-4mo: C. trachomatis, S. pnumo, CMV, mycoplasma hominis, ureaplasma
    • tx: erythro, azithro, or cefotaxime
  • 6w-4y LOBAR: S. pneumo
    • tx: amox, clinda, ceftriaxone or cefotaxime
  • >4y LOBAR: S. pneumo
    • tx: [amox, clinda, ceftriaxone or cefotaxime] AND macrolide (clarith, azith)
  • 6w-4y ATYPICAL: B. pertussis
    • tx: erythro, azithro, clarithro
  • >4y ATYPICAL: mycoplasma, chlamydia, or influenza
    • tx: clarith, azith, eryth, doxy, zanamivir or oseltamivir
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9
Q

foreign body aspiration

A
  • hx: playing with small toys
    • nasal: seeds and beads → MCC of halitosis
  • sxs: acute choking or coughing episode, rhinorrhea, bleeding, halitosis, foul smell
  • signs: exp wheeze, unilateral, asymmetrical dec breath sounds, localized wheeze
  • dx: AP exp XR: tracheal deviation and mediastinal shift AWAY from affected side, hyperinflation, and air trapping in affected lung
  • tx: EMERGENT rigid bronchoscopy
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10
Q

asthma

A
  • characteristics: airway inflammation, airway hyperresponsiveness, reversibleairflow obstruction, may begin at any age, dyspnea common when rapid changes in temp or humidity
  • extrinsic: Atopic: produce IgE dt enviro triggers (eczema, hay fever), become asthmatic young
  • intrinsic: not related to atopy of enviro factors
  • want to see increased FEV1 >12% with albuterol
  • can also see decrease in FEV1 >20% with methacholine or histamine challenge
  • increase in diffusion capacity of lung for DLCO
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11
Q

asthma characteristics and signs

A
  • Triggers: pollens, house dust, molds, cockroaches, cats, dogs, cold air, viral infxns, tobacco smoke, meds (BB, ASA), exercise
  • sxs: SOB, wheezing, chest tightness, cough (occurs in 30 mins to exposure to triggers, sxs worse at night)
  • signs: wheezing (inspiration and expiration) is the MC finding
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12
Q

asthma dx and tx

A
  • Dx: CXR for first time wheezers, PFTs required to dx, spirometry before and after bronchodilators - increase in FEV1 ro FVC by 12%
  • Tx 1:
    • SABA for acute attacks (onset 2-5 min, lasts 4-6h
    • LABA (salmeterol) for nighttime asthma and exercise induced
    • ICS: moderate to severe asthma, use reg to decrease airway hyperresp.
  • Tx 2:
    • Montekukast: proph for mild exercised induced and control of mild-moderate, allows for reduction in steroid and B2
    • Cromolyn sodium: proph before exercise
    • Avoid BB in asthmatics
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13
Q

acute asthma exacerbation

A
  • sxs: sweating, wheezing, speaking incomplete sentences, tachypnea, paradoxical mvmt of abdomen, use of accessory mm.
  • dx: PEFR: low, severe <60
    • ABG: increased A-a gradient
    • CXR: ro pneumonia, pneumothorax
  • tx 1: nebulizer (SABA) or MDI, IV or oral steroids, IV magnesium (prevent bronchospasm)
  • complications:
    • status asthmaticus: doesnt respond to standard meds
    • ARDS: resp mm fatigue
    • pneumothorax, atelectasis, pneumomediastinum
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14
Q

Acute/Chronic bronchitis

A
  • etiology: viruses (most), cannot distinguish acute bronchitis from URTI in first few days
  • sxs: cough >5d (+/- sputum), lasts 2-3wks
    • chest discomfort
    • SOB
    • +/- fever
  • dx: labs not indicated, unless pneumonia suspected (HR >100, RR >24, T >38C, rales, hypoxemia, mental confusion, or systemic illness)
    • CXR
  • Tx: abx not recommended since most viral
  • sxs based tx: NSAIDs, ASA, tylenol, and/or ipratropium
    • abx and cough suppressants not indicated
      • cough suppressants: codeine-containing cough meds
      • bronchodilators (albuterol)
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15
Q

Community acquired PNA

A
  • occurs when there is a defect in pulm defense mech (cough reflex, mucociliary clearance, immune response)
  • urinary Ag for Strep pneumo helpful screening tool in pts w/ leukopenia, asplenia, alcohol use, chronic liver dz, pleural effusion, ICU
  • urinary Ag for Legionella helpful in pts with alc use, travel previous 2 wks, pleural effusion, ICU
  • broad spectrum B-lactamase species: enterobacter, klebsiella pneumo, e. coli
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16
Q

community acquired PNA (pneumo PNA) in immunocompetent: etiology, RF, sxs

A
  • MCC: s. pneumo, H flu, Myco PNA, S aureus, N meningitidis, M catarrhalis, K PNA, other GNR
  • viruses: influenza, RSV, adeno, parainfluenza
  • Occurs outside hosp or within 48hr of hosp admission
  • RF: old, alcoholic, smoker, asthma, COPD
  • MCC pulm dz in HIV pts
  • sxs: fever, cough (with or without sputum), SOB, sweats, chills, rigors, chest discomfort, pleurisy, hemoptysis, fatigue, myalgias, anorexia, HA< abd pain
  • signs: fever or hypotherm, tachypnea, tachycardia, O2 desat, insp crackles and bronchial breath sounds, dullness to percussion
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17
Q

CAP in immunocompetent: dx

A
  • dx:
    • imaging:
      • CXR (patchy airspace opacities to lobar consolidation with air bronchograms) - not necessary in outpt bc empiric tx is effective, recommended if unusual presentation, hx, or inpt, clearing of opacities can take 6 wk or longer
      • CT: more sensitive and specific
    • Labs: sputum gram stain (not sensitive or specific for strep pneumo), urinary Ag test for strep pneumo and legionella, rapid Ag test for flu, pre-antibiotic sputum and blood cultures, CBC, CMP, LFTs, bilirubin, ABG in hypoxemic pts, HIV testing, procalcitonin-released by bact toxins and inhibited by viral infxn
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18
Q

community acquire PNA in immunocompromised pts

A
  • etiology: HIV (ANC <1000), current or recent exposure to myelo or immunosuppressive medications, or pts taking chronic steroids
  • dx: sputum induction, BAL (r/o PCP PNA)
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19
Q

Nosocomial PNA

A
  • Pathogens: s. aureus, K. PNA, E. coli, pseudomonas aeruginosa
  • sxs: at >/= 2 of the following: fever, leukcytosis, purulent sputum
  • dx: CXR, blood cultures x2, CBC and CMP, sputum culture and gram stain (not sensitive or specific), ABG, thoracentesis if effusion, procalcitonin
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20
Q

pneumocystis pneumonia

A
  • pneumocystis jirovecii - caused by fungus found in lungs of mammals
  • MC opportunistic infxn in HIV/AIDS
  • sxs: fever, SOB, nonproductive cough, exam findings disproportionate to imaging showing diffuse interstitial infiltraties, fatigue, weakness, weight loss
  • dx: CXR (definitive): diffuse or perihilar infiltrates, reticular interstitial PNA or airspace dz that mimics pulm edema (5-10%) normal CXR, absent pleural effusions)
    • sputum wright-giemsa stain or DFA (direct fluorescence Ab) - definitive in 50-80%
    • BAL - definitive in 95%
    • CD4 <200 - if AIDS
    • ABG; hypoxia, hypocapnia, reduced DLCO
    • increased LDH but nonsepcific, serum B-glucan is more sensitive and specific, WBC low
  • tx: Bactrim, add steroids if PaO2 <79 or A-a gradient >35 if given in 72h, dapson if sulfa allergy, all pts with CD4 <200 should undergo proph
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21
Q

PNA tx: outpatient, smokers, and inpatient (non-ICU)

A
  • Outpt: 5 days minimum or until pt afebrile x48-72h
    • pathogens: S pnemo, M pneumo, C pneumo, flu virus
    • Previously healthy, no recent abx: macrolide (clarithro or azithro x4d), doxy
    • At risk for drug resistance (old, comorbid, immunosuppress, exposure to child in daycare): respiratory FQ (moxiflox), macrolide plus B lactam
  • Smokers: Cefdinir
  • Inpt, non-ICU:
    • Pathogens: S pneumo, Legionella, H flu, Enterobact, S aureus, Pseudomonas
    • First line: Resp FQ (IV levo), or IV cipro
    • If at risk for pseudomonas: IV macrolide plus IV B lactam (HD ampicillin or Ceoftaxime or ceftriaxone)
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22
Q

PNA tx: hospitalized or ICU pts

A
  • Duration: 5d minimum or until pt afebrile x48-72h
  • ICU: S pneumo, Legionella, H flu, Enterobact, S aureus, Pseudomonas
  • Previously healthy: Azithro or resp FQ (moxi or levo) plus cefotaxime, ceftriaxone, or UNASYN
    • if B lactam allergy: FQ plus Aztreonam
  • pts at risk for drug resistance: Antipneumococcal and antipseudomonal B lactam: Zosyn, cefepime, imipenem or meropenem PLUS:
    • cipro or levo, OR, antipneumo B-lactam (cefotaxime, ceftriaxone, UNASYN) PLUS Aminoglyc (gent, tobra, amikacin) PLUS Azithro or resp FQ
    • If at risk for MRSA: add vanco or linezolid
23
Q

PNA tx: nosocomial PNA

A
  • previously healthy: ceftriaxone, moxi, levo, cipro, UNASYN, Zosyn, or ertapenem
  • at risk for drug resistance: one agent from each:
    • Antipseudomonal
      • Cefepime, Impenem, Zosyn, or aztreonam (if PCN allergy)
    • Second antipseudomonal
      • Levo, cipro, gent, tobra, or amikacin
    • MRSA coverage
      • vanco or linezolid
24
Q

When to admit for PNA

A
  • CURB-65 Score
      1. confusion
      1. uremia
      1. resp rate
      1. blood pressure
      1. age >65
  • <1 = no hosp
  • 1-2 = hosp (maybe ICU)
  • 3+ = definite ICU admit
25
Q

Tuberculosis

A
  • can present as acute or latent infxn
  • only active TB is contagious (cough, sneezing), PRIMARY TB IS NOT CONTAGIOUS
  • difficult to dx in HIV, PPD will be neg, atypical CXR findings, sputum likely neg, granuloma may not be present
  • RF: HIV, immigrants, prisoners, health care workers, close contact, alcoholics, DM, steroids, blood malig, IVDU
  • MC: mycobacterium tuberculosis, slow growing
  • Transmission: inhalation of aerosolized droplets
  • sxs: fatigue, weight loss, fever, night sweats, productive cough
  • dx: sputum stain (acid fast bacilli), sputume culture + for M. tuberculosis, PPD, CXR (caseating granuloma formation (pulm opacitis, most often atypical)
  • tx: RIPE tx, dc tx if transaminases >3-5x ULN, can spread to vertebral column
26
Q

Primary, Secondary, and Extrapulmonary TB

A
  • Primary: bacilli inhaled and deposited into lung - ingested by alveolar macrophages
    • surviving orgs multiply and disseminate via lymphatics and blood
    • granulomas form and “wall off” mycobacteria - remains dormant
    • insults on immune syst reactivates (5-10%)
    • Asymptomatic: pleural effusion, can be progressive with pulm and constitutional sxs, usually clinically and radiographically silent
  • Secondary: Host’s immunity weakened (HIV, malignancy, steroids, substance abuse, poor nutrition), gastrectomy, silicosis, DM)
    • most oxygenated parts of lung: apical/posterior segments
    • Symptomatic: fever, night sweats, weight loss, malaise, chronic cough, progressive (dry to purulent, blood streaked)
      • signs: chronically ill appearing, malnourished, posttussive apical rales
  • Extrapulmonary TB: impaired immunity cannot contain bacteria - disseminates (HIV)
    • any organ
    • Miliary TB: hematogenous spread - can be due to reactivation or new infxn, HIV pts, organomegaly, reticulonodular infiltrates, choroidal tubercles in eye
27
Q

TB diagnostics

A
  • high index of suspicion depending on RF and presentation
  • CXR - unilateral apical infiltrates with cavitations, hilar and paratracheal lymph node enlargement, pleural effusions, Ghon complex, Ranke complex
    • HIV may show lower lung zone, diffuse, or miliary infiltrates
  • Sputum studies: definitive dx by sputum culture, obtain 3 morning sputum speciments, takes 4-8wks, PCR can detect specifics
  • PPD (Mantoux test): screening to detect previous TB exposure, not for active TB dx; if + use CXR to r/o active TB
    • if sxatic or abnl CXR, order AFB
    • >15mm if no risk factors; >10 if high risk (homeless, imigrants, health care workers, DM); >5 if very high risk (HIV, organ transplant, contact with active TB)
  • Interferon gamma release assay: measures interferon gamma release in response to MTB antigens, helps exclude false + TST
  • blood cultures
  • NAAT-R
28
Q

signs of healed primary TB:

A
  • Ghon complex: calcified focus with associated lymph node
  • Ranke complex: Ghon complex undergoes fibrosis and calcification
  • CXR: fibrocavitary apical dz, discrete nodules, pneumonic infiltrates usually in apical or posterior segments of upper lobes or in superior segments of lower lobes
29
Q

TB treatment: active TB, Pregnant women, Latent TB, Immunnocompetent, HIV pos

A
  • Active TB: droplet precautions; isolation until sputum neg for AFB
    • 2 months of tx with 4 drug RIPE, then 4 months with INH and Rifampin
    • once isolate determined to be isoniazid sensitive, ethambutold can be DCed; if susceptible to isoniazid and rif, may continue on 2-drug regimens
    • tx >/= 3 mos past neg cxs for MTB
  • Pregnant: DONT TAKE PYRAZINAMIDE: RIE x 2mo, then isoniazid and rif for 7 mo; B6 (pyridoxine) daily to prevent periph neuropathy; breastfeeding NOT contraindicated
  • Latent (+ PPD): 9mo INH AFTER active TB excluded via CXR, sputum, or both; NOT infxous, no active dz
  • Immunocompetent: INH x9mo; adverse effect = drug induced hepatitis
  • HIV pos: 9mo INH OR 2mo rif and pyrazinamide OR rif x 4mo
  • Other: 9 mo tx when miliary, meninegal or bone/jnt dz; surgical drainage and debridement of necrotic bone in skeletal dz; steroid tx to prevent constrictive pericarditis and neuro complications
30
Q

Pulmonary neoplasm

A
  • Risk factors: cigarette smoking (>85%) increased risk with increasing pack yrs
    • Adenocarcinoma = lowest association of smoking
    • Asbestos
    • Radon
    • COPD
  • Metastatic dz: brain, bone, adrenal glands, liver
31
Q

Small cell lung cancer

A
  • 25%
  • Sxs: recurrent PNA, anorexia, weight loss, weakness, cough
  • Associated sxs: superior vena cava syndrome (facial fullness, edema, dilated veins over ant chest, arms, face, JVD, phrenic nerve palsy, recurrent laryngeal nerve palsy (hoarseness), Horner syndrome (unilateral facial anihdrosis, ptosis, miosis), malignant pleural effusion, Eaton-Lambert syndrome (similar to myasthenia gravis)
  • Dx: CXR (not for screening), CT chest (staging), bx (histologic type), cytologic exam of sputum (central tumors), fiberoptic bronchoscope (central dz), PET scan, transthoracic bx (peripheral dz), mediastinoscopy (advanced dz)
  • Tx: chemo and radiation
    • if dz is extensive, chemo only and then radiation if it is responsive to chemo
  • Prognosis:
    • Limited: 10-13% 5y survival
    • Exstensive: 1-3% 5y survival
  • Staging: limited = confined to CHEST and supraclavicular nodes (not cervical or axillary); extensive = outside chest and supraclavicular nodes
32
Q

Non-small cell lung cancer

A
  • Etiology: SCC, adeno, large cell, bronchoalveolar cell
  • sxs: cough, hemoptysis, obstruction, wheezing, pancoast syndrome (superior sulcus tumor - shoulder pain, radiates down arm, pain and upper extremity weakness dt brachial plexus invasion, horner syndrome)
  • associated sxs: paraneoplastic syndromes (SIADH, ectopic ACTH, PTH-like secretion, hypertrophic pulm osteoarthropathy)
  • dx: CXR (pleural effusion) - always perform bx for intrathoracic lymphadenopathy
  • tx: surgery = best option (if met outside chest, not candidate; may recur after surgery)
    • Radiation: important adjunct, chemotherapy has an uncertain benefit
  • staging: primary TNM staging
33
Q

lung cancer screening

A
  • annual screening for lung cancer with low-dose CT 55-80yo w/ 30 pack/yr hx and currently smoke or quit within past 15yrs
  • discontinue screening once person stops for 15yrs or develops health prob that substantially limits life expectancy
34
Q

Solitary Pulmonary Nodules

A
  • single, isolated, less than 3cm, well-circumscribed nodule or “coin lesion” with no associated mediastinal or hilar lymph node involvement (determines if malignant)
  • RF for malignancy: age 30+, smokers, more cigs per day, prior malig
  • sxs: asxatic (incidental on CXR)
  • dx: review old imaging studies (compare with prior studies, estimate doubling time)
    • CT chest for any suspicious SPN, flexible bronchoscopy (central lesions), transthoracic fine needle bx (FNA) - determines if malignant, PET scan
  • tx: see tx based on probability of malig below
  • prognosis: significant risk of malignancy (10-68%)
35
Q

Pleural effusion

A
  • common after upper abd operations
  • highest risk: pts with free peritoneal fluid and postop atelectasis
  • may suggest subdiaphragmatic inflamm (subphrenic abscess, acute pancreatitis)
  • abnl collection of fluid in pleural space resulting from excess fluid production, dec absorption, or both
  • typically detected by physical exam or thoracic imaging studies
  • sxs: dyspnea, cough (mild nonproductive), CP, inc lower extrem edema, orthopnea, PND
    • NO physical exam findings if <300 mL, otherwise:
      • dullness to percussion, decreased tactile fremitus, egophony changes in superior aspect, decreased breath sounds, asymmetrical chest expansion, mediastinal shift away from effusion if >1000mL, pleural friction rub
  • dx: diagnostic thoracentesis, CXR
  • tx: spontaneous resolution (if not compromising airway fn leave alone), if suspicious for infection, sample by needle aspiration, if respiratory compromise, drain with thoracostomy tube, indications for urgent drainage (frank purulent fluid, pleural fluid pH <7, loculated effusions, bacteria on gram stain or cx)
36
Q

light’s criteria

A
  • pleural fluid protein:serum protein ratio > 0.5 (less prot in blood)
  • pleural fluid LDH:serum LDH > 0.6 (less LDH in the blood)
  • pleural fluid LDH > 2/3 ULN serum LDH
  • exudate if any 1 of the above criteria is met, otherwise usually transudate
37
Q

shortness of breath (dyspnea)

A
  • dyspnea: a term used to characterize a subjective experience of breathing discomfort that is comprised of qualitatively distinct sensations that vary in intensity. experience derives from interactions among multiple physioclogical, psychological, social, and environmental factors
  • clues to need urgent evaluation - heart rate >120 beats/min, resp rate >30 breaths/min, pulse ox sat <90%, use of accessory resp muscles, difficulty speaking in full sentense, stridor, asymmetric breath sounds or percussion, diffuse crackles, diaphoresis, and cyanosis
38
Q

pulmonary embolism RF and sxs

A
  • thrombus embolizes to pulm vasc tree via RV and pulm artery → causes cor pulmonale (severe)
  • MC site → distal to bifurcation of main pulm artery in main lobar, segmental, or subsegmental branches of pulm a; saddle → bifurcation of main pulm a
  • incidence = M>F
  • RF: age >60y, malig, prior hx, hypercoag, prolonged immobilization or bed rest, long-distance travel, cardiac dz, obesity, nephrotic syndrome, major surg or major trauma, preg, E use (OCP)
  • Virchows triad: hypercoag, venous stasis, endothelial injury
  • sxs: dysp (at rest or with exert), pleuritic chest pain (worse with insp), cough, calf or thigh pain or swelling, wheezing, hemoptysis, syncope
  • signs: tachypnea, tachycardia, rales, dec breath sounds, accentuated pulm component of S2, JVD, fever
  • signs of RVHF: hypoTN and JVD, R-sided S3, parasternal lift, cyanosis
39
Q

pulmonary embolism diagnostics and tx

A
  • dx: CXR, D dimer (if low clinical suspicion - do first), EKG (tachy and non specific ST and T wave changes - <10% shows S1Q3T3), + CT pulm angiogram w/ contrast (GOLD STANDARD), VQ scan, normal CXR required prior → test of choice in pregnancy, contrast allergy, and pts with renall insuff, doppler US of lower extrem, Increased A-a gradient, ABG shows resp alkalosis
  • tx: O2, hemodynamically unstable (IVF, vasopressors: NE), anticoag
  • prognosis: recurrenc common
  • poor prognostic factors: hyponNa, elevated lactate, leukocytosis, age >65
40
Q

influenza

A
  • orthomyxovirus
  • transmission: resp droplets, winter months
  • sxs: rapid onset of fever, chills, malaise, myalgia (legs or lumbosacral area), fever, HA (generalized or frontal), nonproductive cough (may last more than 1 wk), ocular signs/sxs (pain w/ motion of eyes, photophob, bruning of eyes), sore throat, +/-N
  • signs: cervical LAD, rhonchi, wheezes, scattered rales
  • dx: RT-PCR = most sensitive and specific (can differentiate subtypes and detect avian flu
  • tx: supportive care (tylenol or NSAIDs . for HA, myalgias, fever; no cough suppressants, neruaminidase inhib: zanamivir or oseltamivir for flu type A and B → reduces sxs by 1-1.5d if started w/in 2 days of onset
41
Q

pertussis etiology, RF, and sxs

A
  • Bordetella pertussis - G- coccobacilus, highly contagious during catarrhal stage, transmitted via resp droplets
  • incubation period = 7-10d, more than 50% of cases occur in adolescents and adults - serve as a reservoir for infxn of infants and children
  • sxs:
    • catarrhal stage (1-2wk): insidious onset of sneezing, rhinorrhea, loss of appetite, malaise, hacking cough at night (most infxs state)
      • signs: gagging, cyanosis, inc work of breathing, sweating
    • paroxysmal stage (2-8wk): spasms of rapid coughing fits during expiration followed by deep, high-pitched inspiratory “whoop”, last several minutes, posttussive emesis or syncope
    • convalescent stage: dec in frequency and severity of paroxysms, begins 4wk after onset of cough and lasts several wks
42
Q

pertussis dx and tx

A
  • dx: most accurate during catarrhal phse, dx mostly clinical (cough >2wk required), microbiological testing required to ocnfirm; culture and PCR assays if cough for 2-4wk, cx = GOLD STANDARD, must use dacron or calcium alginate swab to obtain from posterior nasopharynx; serology = alternative to cx for cough after 4+wk, WBC count = elevated, lymphocytosis
  • tx: abx during catarrhal phase (dec severity and duration of cough, indicated for cough <3wk or 6wk for preg women, health care workers, or child care workers)
    • macrolides (azithro, clarithro, erythro)
    • macrolide intolerant (bactrim DS, ampicillin)
  • prophylaxis: single Tdap booster for adults 16-64y, postexposure prophylaxis for close contacts
  • complications: infxn (PNA, otitis media)
43
Q

pertussis tx based on age

A
  • infants <1mo: azithro x5d, erythro (both are associated with inc risk hypertrophic pyloric stenosis)
  • infants and children >1mo: azithro x5d, clarithro x7d
  • children >2mo: macrolides, bactrim
44
Q

acute epiglottitis etiology and sxs

A
  • 3Ds: dysphagia, drooling, distress
  • pathogen: H. flu type B (MCC, now rare dt vax), S. pneumo, GAS, MRSA
  • infectious causes: psudomonas, candida
  • noninfectious causes: thermal injury, FB, caustic ingestion
  • RF: lack of IMZ for Hib, inflamm of epiglottis and adjacent supraglottis stuctures, results form bacteriemia or direct invasion of epithelial layer
  • sxs: rapid, abrupt onset in kids
    • difficulty breathing, muffled speech (hot potato voice), sudden onset high fever, severe sore throat, dysphagia, absent cough or hoarseness, anxiety, restless, irritable
  • signs: resp distress (stridor), drooling, difficulty swallowing, pharyngitis, tripod position, neck hyperextended, chin thrust forward, insp retractions, appear toxic
45
Q

acute epiglottitis dx and tx

A
  • dx: direct or fiberoptic laryngoscopy (GOLD STANDARD) - erythematous, edematous epiglottis; lateral x-ray (thumb sign, loss of vallecular air space, thickened folds, distende hypopharynx), labs not routinely performed, CBC, blood cx, throat/epiglottis cx
  • tx: MEDICAL EMERGENCY, stabilize airway (mainstay), BVM, supplemental O2, endotrach tube, emergent tracheostomy
    • abx x7-10d (3rd gen ceph)
    • AND antistaph agent (vanco or clinda)
  • prevention: Hib vaccine, pneumococcal vaccine
  • complications: airway obstruction, epiglottic abscess, secondary infection, necrotizing epiglottitis, death
46
Q

hyaline membrane dz (respiratory distress syndrome)

A
  • deficiency of surfactant: dec prod and sec
  • peak: 48-72hrs after delivery
  • MCC resp distress in PREMATURE INFANT
  • sxs: SOB (dyspnea), exp grunt
  • signs: cyanosis and poor response to O2, poor breath sounds, dec pulses, tachypnea, nasal flaring, retractions: suprasternal, subxiphoid, intercostal, subcostal
  • dx: CXR → reticular granularity, air bronchograms, bell-shaped thorax, diffuse bilat atelectasis (ground glass appearance)
  • tx: mech vent, O2, tracheal surfactant, supportive care, maternal roids (prophylaxis)
47
Q

Wheezing

A
  • differential: status asthmaticus, bronchiolitis, lower airway foreign body, allergic rxn (if insp - croup or upper airway foreign body; wheezing w/o fever - atypical PNA, atelectasis, bronchiolitis, asthma, anaphylaxis, pulmonary edema, chronic pulm dz exacerbation, heart failure, foreign body, mediastinal mass)
  • diffuse exp wheeze sign of lower airway intrathoracic obstruction typically caused by asthma or bronchiolitis
  • insp wheeze indicates upper airway extrathoracic obstruction or severe firxed intrathoracic . obst and are most commonly dt laryngeal edema or a foreign body
  • evaluation: pulse ox, CBC w diff, blood glucose, lytes, blood gas, urine, CSF, ABG, XR, EKG, US, CT
48
Q

hemoptysis

A
  • expectoration of blood
  • hx: how much blood coughed in 24-48h, is blood mixed with white or purulent phlegm, what is the frequency of hemoptysis, is this new or recurrent, is pt dyspneic, are there other sxs to suggest infection (fever, chills, night sweats), are there any . sxs to suggest systemic dz (rash, hematuria, jnt pain, swelling)
  • signs: sputum color or purulent secretions, tachypnea, tachycardia, accessory muscle use, cyanosis, diaphresis, focal wheeze or diffuse crackles, heart murmur, palpable purpura, telangiectasia, peripheral edema, jnt effusions or periarticular warmth
  • dx: hgb/hct - assess magnitude and chronicity of bleed, cbc, UA, LFTs and coag, sputum cx or serologic testing for ANA, ANCA, or other Ab, CXR (most important for all persons), BNP or pro-BNP - if cardiac causes suspected, consider D-dimer
  • tx; cause and location guide tx (mild to mod with good gas exchange: no hospitalization required), supportive care (adequate vent, airway support, control hemoptysis, monitor pulse ox)
49
Q

pleuritic chest pain

A
  • pain with forceful breathing mvmt (taking deep breath, talking, coughing, or sneezing), MC potentially life-threatening cause: pulmonary embolism
  • differential: pericarditis, PNA, MI, PTX, etc.
  • tx: control pleuritic CP with NSAIDs (1st line) - typically indomethacin, tx underlying cause
50
Q

ARDS

A
  • an acute hypoxemic resp failure following a systemic of pulmonary insult w/o evidence of heart failure, effects of inc pulm fluid same as cardiogenic pulm edema, but the cause is different
  • RF: sepsis (MC) dt PNA, urosepsis, wounds, aspiration, severe trauma, fxs, acute pancreatitis, multiple or massive transfusions, drug OD/toxins, intracranial HTN, cardiopulmonary bypass
  • sxs: rapid onset dyspnea 12-48h after initial event
  • signs: labored breathing, tachypnea, tachycardia, retractions, crackles, progressive hypoxemia unresponsive to O2 (Pao2: Fio2<300mmHg), difficulty ventilating dt high peak airway pressures (stiff, noncompliant lungs)
  • dx: CXR (diffuse bilat pulm infiltrates with air bronchograms), ABG (resp alk - paco2<40) initially -> resp acidosis dt tachypnea), pulm artery catheter (PCWP low), bronchoscope with bronchoalveolar lavage if acutely ill; cx fluid and analyze (cell diff, cytology, gram stain, silver stain)
  • tx: O2 > 90%, tracheal intubation, mech vent with PEEP, volume overload (diuretics versus vasopressors), treat underlying cause, nutrition (tube feeds>parenteral feed)
  • prognosis: mortality = 30-40%, if complicated by sepsis, rate is 905
51
Q

pulmonary edema

A
  • from ARDS - increase in alveolar cap perm vs. cardiogenic pul, edema - congestive hydrostatic forces
  • sxs: cough, SOB
  • signs: volume overload, JVD, periph edema, hepatomegaly
  • associated: CHF
52
Q

PTX

A
  • air in the pleural space
  • spontaneous primary (simple): w/o underlying dz (healthy), spontaneous rupture of subpleural blebs, MC in tall, lean men, 50% recurrence in 2y
  • secondary (complicated): underlying lung dz (MC = COPD), asthma, ILD, neoplasm, CF, TB, life threatening
  • truamatic: iatrogenic
  • sxs: ipsilateral CP, sudden onset, dyspnea, cough
  • signs: dec/absent tactile fremitus, mediastinal shift toward affected side, dec breath sounds over affected side, hyperresonance
  • dx: CXR confirms DX (visceral-pleural line)
  • tx: small and asxatic - observ 10d +/- small chest tube; large +/- sxs = O2 with chest tube; secondary = chest tube drainage
    • repeatt CXR daily until resolved
53
Q

tension PTX

A
  • air in pleural space; tissue surrounding opening acts as valve: air can enter but not leave, accumulation of air under pressure leads to collapse of ipsilateral lung - shifts mediastinum AWAY from affected side
  • causes: mech vent, CPR, trauma
  • sxs: hoTN (cardiac filling impaired dt compression), distended neck veins, shift of trachea away from affected side, dec . breath sounds, hyperresonance
  • dx: XR not necessary as this is med emergency
  • tx: chest decompression with large-bore needle (2nd or 3rd ICS MCL), followed by chest tube placement

R9 - Emergency Medicine (12 decks)

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