RESPIRATORY Flashcards
When will a D-Dimer always be positive?
In a pregnant woman
How do we know from the doorway if a patient is really sick or not?
Respiratory distress = tripod, use of accessory muscle, drooling, and speaking in 3-4 word sentences, audible wheeze
What’s important about vital signs in the ED setting?
You must always be able to explain abnormal vital signs
What type of questions should you ask in someone with respiratory distress with a history of asthma?
First – use Yes/No questions
Always ask: Have you been intubated before?
Have you been on prednisone?
Is this your asthma?
Are you getting tired?
What are some risk factors to an asthma exacerbation?
Current or recent steroid use
Comorbid conditions
Serious psychiatric illness
Illicit drug use = cocaine
Low socioeconomic class
What else do we need to ask our patient who is having an asthma exacerbation?
Recent illnesses, exposure to triggers, recent increase in use of rescue meds, how long has this been going on for?
What would be a concerning vital sign in asthmatic?
SAO2
What test should you do right away with an asthmatic and best to monitor it throughout (or at the very least after) treatment?
Peak Flow Meter (PFM) & Sit the patient up ☺
What would you see in a child who is in respiratory distress from an asthma exacerbation?
Intercostal retractions & Abdominal breathing
What are some risk factors for death from asthma?
Prior intubation
Previous ICU admission for asthma
Frequent ED visits for asthma
Hospitalization in the past month
Use of 2 or more albuterol inhalers
Use of A/C
What’s our first go to for an asthma exacerbation?
Inhaled Beta2 Agonist (albuterol) – to relax bronchial smooth muscle, decrease histamine release, and increase mucociliary clearance
CONTINUOUS nebulization (adult = 15mg & child = 7.5mg)
Can you use too much albuterol?
Nope
What are some S/E of albuterol?
Tremor & Tachycardia
- Totally normal!!
What do you need to evaluate after each treatment of albuterol?
subjective response, PE, lung function via PFM
What can a patient use if they are allergic to albuterol?
Levalbuterol (Beta 2 receptor agonist with some beta 1 activity)
So if the patient has already tried lots of albuterol at home – hence why they’re now in the ED – what treatment do you turn to?
Steroids!
Which route works fast… PO or IV? What are the names of the meds for PO vs. IV?
They’re EQUAL
But both take 6 hours to work…
PO = Prednisone
IV = Solumedrol
What about inhaled corticosteroids, do those work for an acute exacerbation?
Negative
How do steroids work for asthma exacerbations?
Inhibit airway inflammation, block leukotriene synthesis, and inhibit cytokine production
Well, your patient is already on steroids and used their albuterol inhaler at home – none of those worked so now what?
Epinephrine
How is Epi administered? Who do we use it on? Who do we go easy on the Epi with?
IM route is superior to SC
Use it on the sickest of the sick
But avoid it in old folks with cardiac problems
Okay, so, your patient tried their albuterol and that failed. You gave the person steroids but they take 6 hours to work. You don’t want to use Epi because it’s too intense (or maybe the person is too old)… but the person is still in distress… what do you use?
Terbutaline!
How does Terbutaline work?
Selective beta2 agonist acting directly on beta2 receptors, relaxing bronchial smooth muscle
What’s another asthma medication that is older, rarely used now days, and is for people who have TERRIBLE asthma since it has such a narrow therapeutic window?
Theophyline
You gave Terbutaline (after everything else) and they’re still not doing well… what can you give them?
Magnesium Sulfate!
What asthma medication is especially good for preggo ladies?
Magnesium Sulfate!
What nebulized treatment is the equivalent of about 25% as dense as room air?
Heliox
What are some significant warning signs of severe asthma exacerbation?
PFM 45mmHg
Mental status changes; cardiac arrhythmias, pulsus paradoxus (>20mmHg), and pneumothorax
So, if a patient with an asthma exacerbation looks really, really sick you decide to get blood gases to monitor them – what do you need to pay attention to the most?
PCO2 → if it’s driving upwards, the higher the number, the closer they are getting to respiratory collapse
If a patient in a prolonged asthma attack that is not being cured by usual treatment, what would you notice on PE, that would make you feel it’s time to intubate them?
Silent lungs!! = because they’re not moving air around
You elect to intubate the person – does that solve your problem?
NO
Although you have a secure airway so you can ventilate, that doesn’t mean you can PERFUSE them… so continue with the treatments previously discussed
What would be some criteria for the need to admit an asthma exacerbation?
Repeat visit within 3 days without improvement; changes in mental status; failure of post-treatment PFM to increase by at least 15% or if absolute PFM is
In order to discharge a patient home what must you do?
Prove it to the chart note – document time and changes in sxs after meds and changes/improvements in PFM
What the hell do you do if your tanking asthmatic is pregnant???
Sit her up & do nothing different!!
Although some of the meds are not ideal for baby, if mom doesn’t get better, baby doesn’t survive
So, what are the big take home points from our discussion on asthma exacerbations?
Lots of nebs
Steroids, terbutaline, Epi, Mg Sulfate
Silent chest not your friend
Document re-examinations
What do you look for on PE in a patient with possible COPD?
Thin, dyspnea on exertion, early AM cough, barrel chest, tachypnea, enlarged accessory muscle, clubbing of fingers, pursed lips, prolonged expiratory phase, and wheeze
Why do people with COPD do pursed lip breathing?
Provides back pressure to help them exhale (and prevent their lungs from collapsing)
What’s the #1 thing we want to avoid in a patient with COPD?
Do everything NOT to intubate them
What’s our first step with a COPD patient?
Supplemental O2 & Medication therapy
What medications do we start with in our COPD patient?
bronchodilators = Ipratroprium nebulized
What medication can we use to manage our COPD patient?
Corticosteroids (start immediately except for mild exacerbations)
What do we have to remember our steroids in COPD patients?
Taper & they still take 6 hours to kick in
After you give the patient Ipratroprium & steroids and they’re still not improving what do we do next?
NIPPV
To decrease the need for intubation; improves gas exchange
What is key to remember about NIPPV?
The patient MUST be able to breath on their own
At what point would we need to remove the NIPPV and intubate our COPD patient?
Change sin mental status
Increased respiratory distress with cyanosis
Acute deterioration or exhaustion
What are some criteria for hospital admission?
Increase in intensity of symptoms
Severe background COPD
Onset of new PE findings (cyanosis)
Failure to respond to initial treatment
New arrhythmias
Older age
Insufficient home support
So your COPD patient was having dyspnea with walking and now all of a sudden they develop dyspnea at rest – what criteria do they meet?
They should be admitted
Often times COPD patients are put on antibiotics – what type?
Macrolides & Florquinolones
Are sputum cultures helpful in choosing a therapy for a COPD patient?
Nope
What can excessive supplemental oxygen cause in someone with COPD?
Respiratory depression and respiratory arrest secondary to loss of their hypoxemia-induced ventilator drive
Is it okay to give a COPD patient high-flow O2 for an hour?
If they are very short of breath – yes. But temporary ONLY
If a person has never smoked a day in their life and they now have all the sxs of someone with COPD, what causes that?
Alpha1-Antitrypsin deficiency (which leads to increased protease tissue destruction and emphysema in adults)
So, what are our take home points for COPD?
Give as much O2 as they need
Steroids and lots of nebs
Try to avoid intubation at all costs
A tall, thin, male is at an increased risk of what?
Spontaneous Pneumothorax
What part of the lung do spontaneous pneumothorax’s most frequently occur?
Apex
A patient has abrupt onset of pleuritic chest pain and is tach, tachypneic, and has decreased breath sounds – what do you think?
Spontaneous Pneumothorax
How do you treat a Spontaneous Pneumothorax?
Depends on the size…
Often do nothing & repeat CXR in 24 hours
If Urgent = chest tube
If emergent = needle decompression
If a patient presents after a severe MVA with chest pain, tachy, tachypneic, and decreased breath sounds – what do you need to do?
Get a CXR
If your CXR comes back with a liquid line with a black air line on your patient in a severe MVA, what do you assume it is?
Assume it’s a hemopneumothorax until proven otherwise
In this patient that had a MVA that you believe has a hemopneumothorax what do you need to look for on exam?
Abnormal wall movements; hyperresonance, tympany, subQ emphysema, and flail chest & sucking chest wound
How do you know if someone has a flail chest?
You can see an area move independently when they breath
What does subQ emphysema feel like?
Rice crispies!
So, for this traumatic hemopneumothorax – what do you do?
Emergent needle decompression & chest tube placement
What is the purpose of the chest tube?
It drains blood from the lungs (definitive treatment)
Where do you put a needle vs. chest tube?
Needle = above the 2nd intercostal in midclavicular line
Chest tube = above 5th intercostal space midaxial line
What are the take home points for pneumothorax?
Remember the classic patient for spontaneous pneumo
Needle early if any concern for tension
Landmarks for needle thoracostomy & chest tube
If you highly suspect a PE in a patient – what do you do?
Just go for the imaging!
If a patient is low risk what do you do first?
PERC rules (you have to pass ALL OF THEM)
What are the PERC rules?
Age 94%
No prior history of DVT/PE
No recent surgery or trauma
No hemoptysis
No exogenous estrogen
No clinical signs suggesting DVT?
*MUST be able to say “correct” to all of them in order to pass all of them
IF you pass PERC what do you do?
Nothing
If you fail PERC what do you do?
Wells criteria
What is the Wells criteria?
sxs of DVT, PE judged most likely diagnosis, surgery or bidridden for more than 3 days during the past 4 weeks, previous DVT or PE, HR >100; Hemoptysis; Active cancer treatment (or within past 6 months)?
Fall into either Low, Moderate, or High risk based off points
If a patient is LOW criteria from Wells – what do you do?
D-Dimer
If a patient is MODERATE or HIGH criteria from Wells – what do you do?
Imaging
What’s the classic triad of a patient with a PE?
Pleuritic chest pain, dyspnea, and hemoptysis (rarely any actually present this way)
What might you see on PE with a PE?
Normal, tachycardic/pneic & hypoxic, diaphoresis, and S3 or S4 gallop
Essentially if a patient is anything but low risk – what do we do?
Imaging
What should we remember about a D-Dimer besides the fact it’s only useful if negative?
It CANNOT be used to r/o PE in any other group but those that are low risk
How do we treat a PE?
ABC’s, O2, Pressors if BP is unstable, Fibrinolysis, and FULL ANTICOAG x 3-6 months
A Patient presents with cough, SOB, fever, malaise, and difficulty taking full breaths x 10 days – what diagnosis are you thinking?
Pneumonia
What’s the mortality rate in pneumonia if untreated?
30%
Would an elderly, immunocompromised, or alcoholic patient have classic sxs of pneumonia?
Nope
What might we see on PE with pneumonia?
Tachypnea, tachycardia, decreased breath sounds, wheezing, rhonchi, altered mental status, or no findings at all…
What types of diagnostics should we do for pneumonia?
CXR
CBC
Blood cultures
Sputum cultures
and ABG’s if super sick
How do you treat pneumonia?
OXYGEN, airway support if needed, Abx
What are some of the common pathogens that cause pneumonia?
H influ; Klebsiella; Staphylococus; Legionella
What types of medications are best to treat pneumonia?
Macrolides & Quinolones
Who do we need to admit for pneumonia?
Unstable vitals
Bilateral pneumonia
Elderly/immune compromised
Significant comorbidities
