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RRCCPA Clinical Medicine I > Respiratory Distress/Disorders Ross Final > Flashcards

Respiratory Distress/Disorders Ross Final Flashcards

1
Q

what is the classic triad of pulmonary embolism?

A
  1. Dyspnea
  2. Chest pain
  3. Hemoptisis (rare)
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2
Q

How can PE also present outside of classic sxs?

A

Dizziness

Weak/tired

Decrease exercise tolerance

cough and no other sxs

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3
Q

What is the pathophys of PE?

A

Virchow’s triad

Inflammation and platelet activation

**Main point is coagulation will outpace fibrinolysis

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4
Q

Patients with no respiratory PMHx will exhibit sxs (i.e. CP and dyspnea) when what percentage of vasculature is occluded?

A

20%

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5
Q

In severe cases of PE, meaning there is a large occlusion, what can this lead to?

A

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)

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6
Q

What percentage of PEs progress to cardiogenic shock? Once this occurs what is survival rate percentage?

A

4-5%

50% survival

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7
Q

Fun fact: What percentage of DVTs are associated w/ PEs even though may be no sxs of PE?

A

50%

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8
Q

What are the components of the deep venous system?

A

Popliteal

Iliac aka pelvic per Ross

Superficial Femoral

Deep femoral

*PISD acronym

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9
Q

What is percentage of pts w/ past unprovoked DVT that will have another DVT w/in 10 yrs?

A

10-15%

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10
Q

PE risk factors (RFs)?

A

Long travel

Obesity

Smoking

OCP (estrogen)

COPD

Hx of clot ANYWHERE

Cancer

Genetic Leiden factor V and/or protein S

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11
Q

Exam findings for PE?

A

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

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12
Q

Which pts are the PIOPED1 and PIOPED 2 studies aimed at?

*These studies determined risk stratification for PEs

A

Patients who have sxs concerning for PE

*NOT for pts who have risk of PE but no sxs

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13
Q

Oh you better know the Wells Criteria for PE. Write them out. Chart provided as answer

A
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14
Q

What about Wells Criteria for DVT

Answer chart provided

*Ross did not stress this as much as PE

A
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15
Q

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?

A

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

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16
Q

Are there labs (not imaging) that you can use for dx of PE?

A

NO!

Even a d-dimer is not diagnostic

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17
Q

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?

A

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

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18
Q

What scan is just as good as CTA for PE in pregnant or contrast allergy pts?

A

MRA

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19
Q

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?

A

Present case to attending before ordering. If positive dimer then you are most likely going to have to CTA pt

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20
Q

What are CXR signs of PE?

A

Hampton’s hump

Enlarged right descending pulm a.

Westermark’s sign

Truncation of pulm vasculature

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21
Q

what EKG findings (if any) could you find raising suspicion for PE?

A

Most common is normal EKG

Most common abnormal finding is inverted T in III

then

Wide S in 1, Q in III

*S1Q3T3

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22
Q

What type of pattern can you see on EKG for PE?

A

“Strain” pattern = poor prognosis

shows assymetric ST depression

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23
Q

You have a high risk PE pt but the CT is negative, what now?

A

Call the radiologist to review report with him

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24
Q

What are the three categories of clinical PEs?

A

Massive > syncope and cyanosis

Moderate > sob, +/- plueritic pain & mild low sats

Small > not clinically sig

**Cannot miss the moderate group

25
Q

What is the tx for massive/sub-massive PE?

For smaller PE?

A

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

26
Q

What are the classification criteria for massive vs submassive PE?

A

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)

27
Q

What causes a spontaneous PNX?

Secondary PNX?

Tension?

A

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

28
Q

RFs for PNX?

A

Concern when taking large inhalation and then valsava

Marfans

Trauma

29
Q

How to dx PNX?

A

Should be from physicla exam (no breath sounds)

Bedside u/s has sensitivity of 98%

Ok to get xr if pt is stable

30
Q

You have an elderly pt w/ 2 rib fx, what should you consider?

A

Consider admission due to high probability of atelectasis then pneumonia/hypoxia

*notes now they consider with 3-4 rib fx

31
Q

Tx for tension PNX (hypotensive, decreased breath sounds, increased WOB)?

A

Immediate needle decompression anterior axillary line b/w 4-5th rib

32
Q

What is needed to d/c pt with small PNX?

A

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

33
Q

MCC for ARDS?

A

Sepsis

then

Severe trauma esp multiple fx, severe CHI, pulmonary contusions

High altitude

ASA/narcotics

Near-drowning (more common with salt water aspiration)

34
Q

Tx of ARDS?

A

O2 and avoid fluid overload

35
Q

Two types of COVID are?

A

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

36
Q

Leukotrines irritate the ____ nerve causing ____ and ____.

A

Vagus, coughing and bronchospasm

37
Q

TNF-alpha when in circulation stimulates the hypothalamus causing?

A

Fever

38
Q

COVID also infects mucosal cells causing decrease in ___ and ___.

A

smell and pharyngitis

39
Q

Does COVID cause n/v?

A

Yes

40
Q

How does COVID cause cardiomyopathy?

A

Through direct damage to myocytes or sepsis

41
Q

which vital signs do you evaluate in COVID pt that would reveal signs of systemic inflammatory response?

A

HR, BP, temp

42
Q

Labs to assess high risk pts with COVID?

A

CBC looking for…

lymphopenia and thrombocytopenia

procalcitonin (normal in viral but if + then covid w/ bacterial infection)

CRP elevated from systemic inflammation

43
Q

What imaging do all covid pts get?

A

CXR to assess pneumonia extent

44
Q

What are most if not all of covid pts receiving medication wise?

A

decadron

45
Q

Is bronchitis a bacterial infection? Who do we give

A

NO!

It is almost always viral. Exception is smokers with productive cough and fever will give abx.

46
Q

When does increased WOB cross over into respiratory distress?

A

When unable to clear lactate build up from diaphgragm and accessory muscle use

47
Q

End tital CO2 should have appx what pressure on capnography?

A

appx 40 (37)

48
Q

What are some causes for increase in end tital CO2 (ETCO2)

A

Decreased respiratory rate

decrease in tidal volume

increase metabolic rate

rapid rise in body temp

49
Q

What is the difference between hypoxia and hypoxemia?

A

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

50
Q

A PaO2 of 60 is equal to what O2 sat?

A

90%

51
Q

What are the normal HR and BP for newborn, infant, toddler, adolescent and younger

A

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)

52
Q

Stridor is usually an inspiratory or expiratory sound?

A

Inspiratory

53
Q

MCC peds SOB broken up into age groups

A

< 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

54
Q

How can you differentiate b/w asthma and bronchiolitis?

A

Trial beta agonist inhaler/neb

55
Q

What is the MCC of bronchiolitis and how to treat?

A

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

56
Q

What pt population is bronchiolitis most dangerous in?

A

Premature infants (age based off of gestational age)

** need to check O2 sats during feeding

** can dx RSV with nasal swab

57
Q

MCC of croup and tx

A

Parainfluenza

tx: steroids dexamethasone 0.6 mg/kg PO/IV and nebulized epi but need to watch for rebound

58
Q

Pneumonia MCC by age groups neonate (0-2 mos), infant (2 mos to 3 yrs), > 3 yrs

A
59
Q

Patient CC that can actually be pulmonary based SOB

A
  • CP
  • Cough
  • Back Pain
  • Dizzy/weak
  • abdominal pain

RRCCPA Clinical Medicine I (49 decks)

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