Respiratory Distress/Disorders Ross Final Flashcards
what is the classic triad of pulmonary embolism?
- Dyspnea
- Chest pain
- Hemoptisis (rare)
How can PE also present outside of classic sxs?
Dizziness
Weak/tired
Decrease exercise tolerance
cough and no other sxs
What is the pathophys of PE?
Virchow’s triad
Inflammation and platelet activation
**Main point is coagulation will outpace fibrinolysis
Patients with no respiratory PMHx will exhibit sxs (i.e. CP and dyspnea) when what percentage of vasculature is occluded?
20%
In severe cases of PE, meaning there is a large occlusion, what can this lead to?
Increased pulm art pressures > RV dilation releasing BNP and troponin > ultimately resulting in cardiogenic shock
**Blood volume stays the same > pulm vasculature is blocked increasing resistance > increasing pressure (same volume in smaller space)
What percentage of PEs progress to cardiogenic shock? Once this occurs what is survival rate percentage?
4-5%
50% survival
Fun fact: What percentage of DVTs are associated w/ PEs even though may be no sxs of PE?
50%
What are the components of the deep venous system?
Popliteal
Iliac aka pelvic per Ross
Superficial Femoral
Deep femoral
*PISD acronym
What is percentage of pts w/ past unprovoked DVT that will have another DVT w/in 10 yrs?
10-15%
PE risk factors (RFs)?
Long travel
Obesity
Smoking
OCP (estrogen)
COPD
Hx of clot ANYWHERE
Cancer
Genetic Leiden factor V and/or protein S
Exam findings for PE?
96% tachypnea (Rs > 16)
58% rales
53% secod heart sound
44% tachycardia > 100 BPM
43% Fever >37.8 C
36% diaphoresis
**Any one of these is enough to consider or r/o PE
Which pts are the PIOPED1 and PIOPED 2 studies aimed at?
*These studies determined risk stratification for PEs
Patients who have sxs concerning for PE
*NOT for pts who have risk of PE but no sxs
Oh you better know the Wells Criteria for PE. Write them out. Chart provided as answer
What about Wells Criteria for DVT
Answer chart provided
*Ross did not stress this as much as PE
What is your next criteria you would use if obtaining a Wells Criteria PE score less than 4 (low to moderate) and what are ALL the criteria that must be met?
PERC (PE r/o criteria)
**If ALL of these are met then chance of PE < 2%, no need for d-dimer
**This is a rule-out criteria, not rule-in
Are there labs (not imaging) that you can use for dx of PE?
NO!
Even a d-dimer is not diagnostic
You have a suspected PE pt who you want to image but they are either pregnant, contrast allergy or have poor renal fx. What imaging can you use instead?
V/Q scan (need CXR as well)
*Not used very often b/c up to 60% of scans are non diagnostic especially if CXR was abnormal or has lung dz. Need to f/u w/ further testing like DVT u/s
What scan is just as good as CTA for PE in pregnant or contrast allergy pts?
MRA
What do you do before ordering a dimer on rotations if you have a pt who is low risk for PE and you cannot use PERC?
Present case to attending before ordering. If positive dimer then you are most likely going to have to CTA pt
What are CXR signs of PE?
Hampton’s hump
Enlarged right descending pulm a.
Westermark’s sign
Truncation of pulm vasculature
what EKG findings (if any) could you find raising suspicion for PE?
Most common is normal EKG
Most common abnormal finding is inverted T in III
then
Wide S in 1, Q in III
*S1Q3T3
What type of pattern can you see on EKG for PE?
“Strain” pattern = poor prognosis
shows assymetric ST depression
You have a high risk PE pt but the CT is negative, what now?
Call the radiologist to review report with him
What are the three categories of clinical PEs?
Massive > syncope and cyanosis
Moderate > sob, +/- plueritic pain & mild low sats
Small > not clinically sig
**Cannot miss the moderate group
What is the tx for massive/sub-massive PE?
For smaller PE?
Massive: 80mg/kg bolus heparin (unfractionated) followed with 18mg/kg/hr
Smaller PE and pt is VERY stable i.e. no dyspnea or pain with inspiration then tx w/ fractionated LMWH (lovenox)
*Lovenox tx depends on standard of practice/clinic
*If wanting to d/c smaller PE pt medicine team with d/c with lovenox instructions and pt will be seen next day
What are the classification criteria for massive vs submassive PE?
Massive: Hypotension from CV collapse (50% of vasculature occluded)
Submassive: Low sats, echso showing R heart failure. Best way to determine is order BNP ( >90pg/mL)
What causes a spontaneous PNX?
Secondary PNX?
Tension?
rupture of sub pleural bleb
underlying pulm process i.e. COPD
Tension PNX intrapleural pressure becomes positive increasing intrathoracic pressure causing restricted venous return and ultimately shock
RFs for PNX?
Concern when taking large inhalation and then valsava
Marfans
Trauma
How to dx PNX?
Should be from physicla exam (no breath sounds)
Bedside u/s has sensitivity of 98%
Ok to get xr if pt is stable
You have an elderly pt w/ 2 rib fx, what should you consider?
Consider admission due to high probability of atelectasis then pneumonia/hypoxia
*notes now they consider with 3-4 rib fx
Tx for tension PNX (hypotensive, decreased breath sounds, increased WOB)?
Immediate needle decompression anterior axillary line b/w 4-5th rib
What is needed to d/c pt with small PNX?
CXR shows small PNX, treat with 100% O2 for 4 hrs then repeat CXR if PNX subsided d/c only if coming back for 24 hr repeat CXR
MCC for ARDS?
Sepsis
then
Severe trauma esp multiple fx, severe CHI, pulmonary contusions
High altitude
ASA/narcotics
Near-drowning (more common with salt water aspiration)
Tx of ARDS?
O2 and avoid fluid overload
Two types of COVID are?
S type and L type
*disease enters through type 2 pneumocytes then inflammation cascade destroys all types fo pneumocytes causing interstitial edema > poor O2 perfusion
Leukotrines irritate the ____ nerve causing ____ and ____.
Vagus, coughing and bronchospasm
TNF-alpha when in circulation stimulates the hypothalamus causing?
Fever
COVID also infects mucosal cells causing decrease in ___ and ___.
smell and pharyngitis
Does COVID cause n/v?
Yes
How does COVID cause cardiomyopathy?
Through direct damage to myocytes or sepsis
which vital signs do you evaluate in COVID pt that would reveal signs of systemic inflammatory response?
HR, BP, temp
Labs to assess high risk pts with COVID?
CBC looking for…
lymphopenia and thrombocytopenia
procalcitonin (normal in viral but if + then covid w/ bacterial infection)
CRP elevated from systemic inflammation
What imaging do all covid pts get?
CXR to assess pneumonia extent
What are most if not all of covid pts receiving medication wise?
decadron
Is bronchitis a bacterial infection? Who do we give
NO!
It is almost always viral. Exception is smokers with productive cough and fever will give abx.
When does increased WOB cross over into respiratory distress?
When unable to clear lactate build up from diaphgragm and accessory muscle use
End tital CO2 should have appx what pressure on capnography?
appx 40 (37)
What are some causes for increase in end tital CO2 (ETCO2)
Decreased respiratory rate
decrease in tidal volume
increase metabolic rate
rapid rise in body temp
What is the difference between hypoxia and hypoxemia?
Hypoxia is insufficient O2 tissue perfusion due to low cardiac output, low Hgb or low O2 sat
Hypoxemia is low arterial oxygen partial pressure of PaO2 < 60
A PaO2 of 60 is equal to what O2 sat?
90%
What are the normal HR and BP for newborn, infant, toddler, adolescent and younger
Newborn: HR up to 180, not lower than 90, RR up to 60, 60/40
Infant: HR up to 160, no lower than 110, RR 50,
Toddler: HR up to 140 no lower than 100, RR 30, 75/50
Adolescent: HR up to 110, RR 20, 90/60
** at one year systolic bp 90 + (age X 2)
Stridor is usually an inspiratory or expiratory sound?
Inspiratory
MCC peds SOB broken up into age groups
< 3 mos = bronchiolitis from RSV/influenza, covid
> 3 mos = pneumonia, asthma, croup (2-5 yrs)
> 3 yrs = strep pharyngitis, pneumonia, croup
**foreign body from crawling age and above
How can you differentiate b/w asthma and bronchiolitis?
Trial beta agonist inhaler/neb
What is the MCC of bronchiolitis and how to treat?
80% RSV infection
- Wheezing does not respond to beta agonists
- lasts up to 21 days, day 3 worst
Tx broken into categories of mild/moderate and severe
Severe: O2 w/ epi neb (0.5mL of 0.1% solution in 3.5 cc NS) consider intubation but should be transfering to childrens hospital
Mild/moderate: supportive care of suctioning and O2 trial beta agonists
What pt population is bronchiolitis most dangerous in?
Premature infants (age based off of gestational age)
** need to check O2 sats during feeding
** can dx RSV with nasal swab
MCC of croup and tx
Parainfluenza
tx: steroids dexamethasone 0.6 mg/kg PO/IV and nebulized epi but need to watch for rebound
Pneumonia MCC by age groups neonate (0-2 mos), infant (2 mos to 3 yrs), > 3 yrs
Patient CC that can actually be pulmonary based SOB
- CP
- Cough
- Back Pain
- Dizzy/weak
- abdominal pain
