Red Flag Flashcards
transudative pleural effusion etiologies
CHF
cirrhosis
nephrotic syndrome
myexedema
exudates pleural effusion cause
bacterial PNA
malignancy
PE
trauma
throacentesis in kids
never go below?
8th rib space
Relative CI for thoracentesis
NO absolute contraindications
- Blood dyscrasia (Pt <50k or elevated anticoag study)
- Cellulitis or similar complicated skin d/o
- Mechanically ventilated
atropine use in pulm proceudres
vasovagal event
heparin
prevent pleural fluid from clotting
diagnostic purposes
why type of thoracentesis?
diagnostic
needle placement
why type of thoracentesis?
therapeutic
needle catheter
causes of dry tap
Needle is too short (Large body habitus?)
Or you picked wrong location (Air bubbles → Too high, hit parenchyma
If neither air nor fluid → Too low)
blood in pleural fluid cause
Trauma, malignancy, infarcted lung, even tTB
MC complication of thoracentesis
PTX
“small PTX”
< 3 cm
from the thoracic apex to the lung cupola
Thoracostomy CI
No absolute CI in unstable patient
If stable: Multiple adhesions, blebs, coagulopathies
where is a needle throacostomy inserted
2 or 3 iCS
ET tube size
ET tube size = (16 + age)/4
about 8 in men (32 Fr) and 7.5 in women (30 Fr)
tube thoracotomy placement
bt 4 and 5 ICS
Max dose lidocaine
+/- epi
7mg w/epi
4 mg w/o epi
risk for arrhythmia
lidocaine % dose
1% lidocaine, 10 mg per 1 mL
2% lidocaine, 20 mg per 1 mL
Blade used to make skin incision for chest tube
11
Surgical expansion after chest tube
Required when
an air leak persists > 72 hours or lung fails to completely expand
Milking v. stripping
Milk towards chest to break up obstruction/clot
Stripping clamps proximal duct.. Strip away from chest
what amount of blood to consider thoracotomy
1-1.5 L blood at time of placement
does a chest tube need ABX prophylactically?
NO need
Bronchoscopy
Performed w/ procedural sedation, often in OR suite
Allows access to third order bronchi
Reasons for diagnostic bronch (3)
Eval PNA
Persistent atelectasis
Hemoptysis
Epi dose 1:20,000
For endobronchial bleeding in bronchoscopy
Relative CI for bronchoscopy
Tachy/bradycardia, bronchospasm, hypoxemia,
bleeding (Platelet 30-50K for
BAl is preferred… Pt 50K for elective procedure),
and HoTN/HTN `
Complication of bronch
Rarely…. Pretty safe
MC complications from sedation (mild transient HoTN, N/V, arrhythmia)
Upper airway
level of larynx (surrounded by thryroid gland/cartilage, cricoid)
lower airway
trachea to lungs
LEMON
look (external structures)
Evaluate (3,3,2)
Mallampati Score
Obstruction
Neck (mobility)
Vocal cord dysfunction
Present with audible wheezes and asthma-like sxs
Paradoxical vocal cord adduction…. Tx speech therapy
May or may not respond to bronchodilators (psychogenic)
Laryngospasm
Closure of glottis by constriction of intrinsic and extrinsic laryngeal muscles, can completely restrict laryngeal muscles
larygngospasm cause
Ketamine, secretions, blood, vomitus, any stimulation of the upper airway
oropharyngeal airway
only useful for those without gag reflex/ unconscious
laryngeal airway
type of advanced airway
blindly performed (positive airway pressure)
useful for when you can’t visual cords
MC BiPAP setting
10/5 inspiration/expiration
NIPPV benefits
Increase lung volume, decrease work of breathing
Less complications
Increase functional residual capacity
Pulmonary fluid redistributed
Preload and afterload are decreased
CPAP settings
5-15 cm H2O
who to NOT intubate
cardiac or respiratory arrest
anticipated airway difficulties
failed airway
3 unsuccessful attempt to intubate
failure to maintain oxygenation
induction agents used
etomidate
propofol
ketamine
Paralytic agents
Succinylcholine, Rocuronium, Vecuronium
Only used for the initial RSI (not continued)
Propofol
Lipophilic, quick on and quick off…..
Risk HoTN, myocardial suppression and vasodilation
etomidate
hypnotic with NO analgesia
ketamine
NMDA receptor agonist
maintains respiratory drive and smooth muscle relaxation
Analgesia, dissociative, amnestic
ketamine s/e
HTN increased Iop emergence rxn laryngospasm increased secretions
Succinylcholine
Depolarizing paralytic agent (MC)
Fast on (60 s) and fast off (2-3 minutes)
Respirations often resume within 12 min
Standard dose: 1.5 mg/kg
succinylcholine ADR:
hyperkalemia, can cause malignant hyperthermia (Dantrolene)
rocuronium
non depolarizing paralytic
intermediate duration of action
ET tube length
Men: 8, Women: 7
Depth: 3x ET tube size marked at teeth
mac blade
3
curved
less trauma
less airway stimulation
miller blade
2
straight
lifts epiglottis
Preoxygenation before intubation
BVM (90-97% O2) and high flow NC, have suction ready
Single vs. Double Comet
Ultrasound confirmation of correct tube placement:
Appropriate placement → Single comet
Inappropriate placement → Double comet
CI for trach
No trachs for kids younger than 8-10 years old (Alt: Jet insufflation)
suspect B pertussis
Cough > 7 days
kids: whooping cough
likely PNA if:
HR > 100 Temp >100.4 RR > 24 Age > 64 no chest exam findings
procalcitonin
elevated in bacterial infection
SARS lab results
increased LFTs
thrombocytopenia
lymphocytopenia
prolonged PTT
