Respiratory CIS Flashcards
most common cause of wheezing in kids
-viral infections
what time of day is more suggestive of asthma
coughing that’s worse in middle of the night
risks for developing asthma
- RSV infection prior to 6 months of age
- FH of any atopy- allergic rhinitis, eczema
common triggers for asthma
- virus
- allergies
- exercise
- cold air
- cigarette smoke
CXR in a child with asthma or reactive airway dz (RAD)
- atelectasis (auscultated as dec breath sounds)
- hyperinflation of both lungs
- perihilar thickening
capillary refill- in healthy child and child with asthma or RAD
- > 2 sec = very concerning
- healthy- nearly instantaneously!!
best way to obtain blood gases in pediatric pt
capillary blood gases
- quicker and less distressing than arterial gas (which is more accurate for O2)
- cant use PaO2 from them
- useful only for pH and CO2
pediatric pt with asthma exacerbation- admitted to?
-PICU- due to significant risk for decompensation
options for maintenance IVF in children
- 1/2 NS in >1 yo or 1/4 NS in <1 yo
- NS is reserved for bolusing
- in peds usually K is added to IVF
when is it appropriate to intubate an asthmatic (pediatric) pt- treatments to add to intubation?
- time to intubate- when b/w irritable and obtunded
- ADD terbutaline drip, Mg, Theophylline, subcutaneous epinephrine, heliox (breathing as that is a mixture of helium and oxygen, less resistance and easier to breath), or BiPAP– in order to NOT INTUBATE an asthmatic
Why don’t you want to intubate asthmatics?
-they can’t exhale- so you force breaths in with the vent, they get fuller and fuller until they either get b/l pneumothorax or acute right heart collapse and die
which population of asthmatics has the highest mortality
-adolescents- b/c they dont carry their rescue inhaler with them
signs of resp distress in a pediatric pt
- inspiratory and expiratory wheezing
- nasal flaring and tachypnea
- subcostal, intercostal, and suprasternal retractions
- stridor
- sniffing or tripod positioning
- dec air movement (after albuterol hear wheezing, means improving)
treatment considerations
- albuterol nebulizer or inhaler (rescue inhaler- bronchodilator- short acting Beta-2 agonist)
- inhaled corticosteroids
- oral corticosteroids
- oxygen (put on first if hypoxic)
what would indicate concern for CF?
- poor height and weight
- clubbing
- foul-smelling stools
- recurrent pneumonia
- edema
- failure to thrive
- test with Sweat chloride test!!`
sudden stridor in a child makes you think of what?
-foreign body aspiration
O2 options to consider
- NC up to 5 Liter
- simple face mask at 5-6L
- NRB at 10-15 L/min
- bag valve mask
- bipap
- intubation
asthma under control- green- YES
- daytime sx- 3 times or less/week
- nighttime sx- none
- reliever- 3 times or less/week
- physical activity- normal
- able to go to school- yes
- peak expiratory flow- 85-100%
- Stay controlled and avoid triggers
asthma under control- yellow- NO
- daytime sx- >3 times/week
- nighttime sx- some nights
- reliever- >3 times/week
- physical activity- limited
- able to go to school- maybe
- peak expiratory flow- 60-85%
- Adjust meds
asthma under control- red- NOT AT ALL
- daytime sx- continuous and worsening
- nighttime sx- continuous and worsening
- reliever- relief less than 3-4 hrs
- physical activity- very limited
- able to go to school- no
- peak expiratory flow- <60%
- call for help
obstetrical history taking- GTPAL
- Gravidity- number of total pregnancies
- Term births- term deliveries (38 wks)
- Preterm births- viability up to 37 wks
- Abortions/miscarriages
- Living children
total hysterectomy
-take uterus and ovaries, usually but not always take the cervix too
CAD risk factors
-emotional stress and no exercise
S2 splitting during cardiac exam- cause
- physiologic splitting of S2 on inspiration can be normal
- persistent splitting of S2 during inspiration and expiration- HD in adults (RBBB), RV pressure overload situations (acute massive PE)
- physiologic splitting of S2 on inspiration can be normal
- persistent splitting of S2 during inspiration and expiration- HD in adults (RBBB), RV pressure overload situations (acute massive P
rales
what is an invasive and highly accurate way of measuring BP constantly?
arterial line
checking for inherited thrombophilia- labs
checking for inherited thrombophilia- labs
most common findings on an EKG in a pt with a PE?
- nonspecific ST-T wave abnormalities
- sinus tachycardia
gold standard imaging choice for PE?
CTA (CT angiogram) of chest (PE protocol)
-need to consider the stability of pt before taking them to radiology!
EKG- indicative of PE
-S1 Q3 T3
what is tPA?
- recombinant tissue type plasminogen activator (alteplase)- “clot buster”
- enzyme produced by a number of tissues, including endo cells- binds to fibrin, which inc its affinity for plasminogen and enhances plasminogen activation
- systemic thrombolysis is preferred- can give rapidly (as compared to taking to cath lab for angiogram and direct injection into the clot itself)
Indications for thrombolytic therapy in venous threomboembolism
- hypotension related to PE
- severe hypoxemia
- substantial perfusion defect
- right ventricular dysfxn assoc with PE
- extensive DVT
hormones are what?
pro-thrombotic
-hormone replacement therapy- premarin (Estrogen)
what is Factor V Leiden?
mutant form of coagulation factor V
- FVL mutation renders factor V insensitive to the actions of activated protein C (aPC), a natural anticoagulant
- FVL mutations- inc risk of venous thromboembolism
- extremely common!!- many pts will never have a VTE
Virchow’s Triad
VTE occurs as a result of:
- alterations in blood flow (stasis)
- vascular endothelial injury
- hypercoagulable state (inherited or acquired)
Wells Criteria
(assessment for PE) -clinical sx of DVT- 3 -other dx less likely than PE- 3 -HR > 100- 1.5 -immobilization or surgery in prev 4 wks- 1.5 -previous DVT/PE- 1.5 -Hemoptysis- 1 -malignancy- 1 SCORE -high >6 -moderate 2-6
contraindications to fibrinolytic therapy?
- prior intracranial hemorrhage
- structural cerebral vascular lesion
- malignant intracranial neoplasm
- ischemic stroke within 3 months
- suspected aortic dissection
- active bleeding or bleeding diathesis
- close-head trauma in last 3 months
types of shock
- hypovolemic
- cardiogenic
- distributive
- obstructive
what is MAP
mean arterial P
- diastolic BP + [(systolic BP - diastolic BP) / 3]
- > 65 = good perfusion to all organs
- <65 = hypotension/hypoperfusion
dd for Tb
- NTM (nontuberculosis mycobacterial infection- M kansaii)
- fungal infection
- lung cancer
- lymphoma
NTM (nontuberculosis myobacterial infection- M kansaii)- sx, dx
- fatigue, dyspnea, occasional hemoptysis
- sputum Cx and molecular diagnostics
fungal infection- sx, dx
- PNA, nodules, cavitation
- dx- Cx results, regional exposure
lung cancer- sx, dx
- fevers, cough, chest pain, hemoptysis, dyspnea
- dx- histopathology
lymphoma- sx, dx
- fevers, night sweats, weight loss
- dx- histopathology
pts at risk for tb
- close contact with someone who has active tb
- immigrants from endemic areas
- jail, nursing homes, homeless shelters, healthcare facilities
- medically underserved, poor populations
- IV drug abuse
- HIV/AIDS
PPD >5 mm induration
- HIV
- close contact with actively infected person
- CXR with fibrotic changes consistent with TB
- immunosuppression
PPD > 10 mm induration
- clinical conditions that INC risk of react- silicosis, DM, chronic renal failure, malignancies
- children < 4
- from country with high prevalance
- jail, healthcare facilities, homeless shelters
PPD > 15 mm induration
-healthy individual > 4 with low likelihood of true TB infection
signs/sx of active tb
-fever, night sweats, cough (>2 wks), weight loss, lymphadenopathy
workup for tb
- Sputum culture
- sputum staining
- PPD skin test
- IGRA
- CXR
- NAAT
TB- sputum culture
- tb is a microbiological diagnosis!!
- 3 separate morning sputum samples
- takes 6-8 wks
- culture is the gold-standard for dx!!!!!
TB- sputum staining
Acid-fast bacillus!!
- Rhodamine-auramine stain- initial screening
- Ziehl-Neelsen and/or Kinyun stain- confirmatory
tb- IGRA- indication
- diagnostics of LATENT tb
- pts who have received a BCG vaccination and those with a positive PPD in whom latent tb is suspected
TB- CXR
-cavitary lesions- apex of lung
TB- NAAT
-detects INH and rifampin resistance
TB- drug therapy and SE’s
- Isoniazid- peripheral neuropathy (give pt Vit B6)!!
- Rifampin- red/orange body fluids
- Pyrazinamide- gout, joint aches
- Ethambutol- optic neuritis, color-blindness
- monitor CMPs- kidney and liver fxn!!!
clinical dx of active TB
- clinical sx
- risk factors
- order radiography
- sputum culture
- dont delay treatment when awaiting sputum culture!!
PPD + with no BCG vaccine
- check CXR- make sure there’s no active TB
- treat as latent tb- 9 months of INH
PPD + with BCG vaccine
- check CXR and IGRA
- if IGRA positive- treat as latent tb
- if IGRA negative- NO active or latent tb
