respiratory emergencies Flashcards
what are the signs of life threatening respiratory distress ?
alterations in mental status
absent breath sounds
pallor and diaphooresis
retracctrion and use of accessory muscles
audible stridor
severe cyanosis
1-2 word dyspnea
what is kussmaul breathing ?
type of hyperventilation in response to acidosis
inspiratory filling of the neck veins
what is carpopedal spasm evidence of ?
hyperventilation induced by hypocapnia
induces spasm in the hand and feet
what is the management of acute exacerbation of chronic airway limitation ?
oxygen therapy
regular bronchodilators
systemic corticosteroids ( prednisolone)
what usually predisposes the happening of a pulmonary embolism ?
virchows triad:
stasis
vessel wall injury
hypercoagulability
all causing thrombosis
what are the clinical feature of pulmonary embolism ?
classic triad of :
sudden onset of shortness of breath
pleuritic chest pain
haemoptysis
small PE may be asymptomatic
what may be present in a chest x ray suggestive of pulmonary embolism ?
pulmonary oligemia
what is the management of blood clot embolus ?
start anticoagulant with low molecular weight heparin adjusted for weight
consider thrombolysis
what is characteristically found in pneumothorax ?
mediastinal shift
what position is pneumothorax best seen in ?
erect view
what is the management of pneumothorax ?
increase FiO2 hypoxaemic
aspirate air on affected side
chest drain insertion
what are the features of acute chest infection ?
fever cough purulent sputum production pleuritic pain bronchial breathing
what kind of antimicrobials are required for cavitations ?
anaerobic bacteria ( metronidazole)
What is the definition of acute respiratory distress syndrome?
non-cardiogenic RF
onset within 1 week of worsening respiratory symptoms
PaO2/FiO2 < 200 mmHg, regardless of level of PEEP
bilateral infiltrates on chest X-ray
pulmonary artery wedge pressure < 18 mmhg
what is the management of ARDS ?
remove the causative agent
maintain mean arterial pressure above 60 mmhg
sedate with an opiate-benzodiazepine
muscle relaxation
high dose corticosteroids
when is stridor observed ?
if there is upper airway obstruction
what is cherry-red skin a sign of ?
carbon monoxide poisoning
how do we spot microatalectasis ?
chest x ray may be normal but A-aDO2 will be high
what is cheyne-stoke breathing ?
oscillating between hyperventilation and apnea
how is disability assessed ?
glucose
ACVPU
pupils
what are the non thrombotic causes of pulmonary embolism ?
fat globules or fetal cells in pulmonary artery blood
what are the ABG findings in PE ?
decreased PaO2 ( v/q mismatch )
decreased PaCo2
later :
High PaCO2
Metabolic acidosis
what are the ECG changes in PE ?
p pulmonale and sinus tachycardia
what are the chest x ray findings in pulmonary embolism ?
1- hampton’s hump - wedge shaped opacity
2- westermark sign - oligemia of lung field
3- fleishner sign - enlarged pulmonary artery
4- Palla’s sign - enlarged right descending pulmonary artery
what is the simplified pulmonary embolism severity index ?
age >80
history of cancer
history of cardiopulmonary disease
pulse above 110
systolic BP less than 100
SaO2 < 90
0 points then the 30 day mortality risk is 1%
if 1 or more then the 30 day mortality risk is 10.9%
what is the value of the d dimer test in PE ?
good negative test
iff there is a high clinical probability of PE what is the next best step in management in a hemodynamically stable patient ?
perform CTPA
what is the first line investigation to perform in a hemodynamically unstable patient who is suspected to have a pulmonary embolism ?
bedside TTE
what is the next step after performing bedside TTE in a hemodynamically unstable patient ?
Iff there is RV dysfunction then perform CTPA
what is the next step in management afte anticoagulant addministration in a haemodynamically stable patient ?
asses the severity of the patient using the following two point :
1- clinical severity and presence of comorbidities
2- RV dysfunction which is assessed by TTE
if any of these factors are present perform a troponin test
if troponin is positive then the patient is intermediate high risk ( consider reperfusion and monitor )
if it is negative then the patient is intermediate low risk ( hospitalize )
what is the management if a patient present with acute PE and is haemodynamically unstable ?
automatically high risk patient and must perform reperfusion and give cardio and pulmonary support
what measure should be taken when providing support for a hemodynamically unstable patient suffering from acute PE ?
after administration of anticoagulant
1- give oxygen therapy and ventilation
2- vasopressin and appropriate fluids for RV dysfunction
3- once anticoagulant is given start CPR for no less than 60-90 minutes
if the patient is confirmedd to have acute PE what is thee first step in managemnt ?
administatiion of anticcoagulant
what should the Fio2 and SpO2 levels in acute PE management be maintained at ?
On FIO2 0.6–1.0 to maintain SaO2 93–98%.
what are the different options for reperfusion therapy ?
systemic thrombolysis (fibrinolysis )
Percutaneous catheter-directed treatment
Surgical embolectomy
what are the absolute contraindications for the use of fibrinolysis ?
history of stroke
CNS neoplasm
major trauma
bleeding tendency
active bleeding
how should the initial anticoagulant be used ?
parenteral anticoagulant along with VKA for 5 days or more until the INR is 2-3 for 3 days
VKA such as warfarin
when are vena cava filters indicated ?
recurrent PE despite adequate anticoagulation
primary prophylaxis for high risk patients
in VTE and patients where AC are contraindicated
what is ARDS ?
non-cardiogenic pulmonary oedema and diffuse lung inflammation
what does the berlin criteria state iin regards to ARDS ?
1- onset within 1 week of insult or new worsening respiratory symptoms
2- bilateral opacities ( that arent lung collapse, nodules or effusion )
3- respiratory failure not due to cardiac reasons fluid overload ( resp wedge pressure must be less than 18 )
4- PaO2/FIO2 ≤300 mmHg, PEEP ≥5 cm H2O
in what stage of ARDS do patients tend to recover ?
in the proliferative phase
what is the most common cause of ARDS ?
sepsis
pancreatitis
what is the organism for acute epiglottitis and what is the treatment ?
organism is usually H. Influenzae treat with Ceftriaxone/chloramphenicol
what to do if intubation is difficult ?
video laryngoscopy
fiberoptic intubation
what to do if intubation is unsuccessful ?
retrograde intubation
cricothyrotomy
tracheostomy
what are the complications of inhalation injury ?
respiratory failure
ARDS
wheen should early bronchoscopy be performed in inhalation injury ?
- Soot
- Debris
- Vomit
what is the management for smoke inhalation ?
- Urgent laryngoscopy
- Endotracheal intubation
- Bronchoscopy with bronchial toilet using warmed
0.9%saline - Benzylpenicillin
*Specific treatment for poisons within
smoke(CO/cyanide)
what is the management for steam inhalation ?
- Consider early/prophylactic intubation
*Consider early bronchoscopy and lavage with cool 0.9%saline
what is the management in cases of aspiration of gastric contents ?
1- early bronchoscopy and physiotherapy
2- cefuroxime plus metronidazole or clindamycin for 5 days
what type of atelectasis happens in ARDS ?
adhesive
what is Luftsichel sign ?
air crescent in Left upper lobe collapse
what are the signs of right sided heart strain ?
raised JVP
parasternal heave
loud p2
What are the causes of massive postoperative lung collapse?
1- aspiration of vomitus due to full stomach
2- post op inadequate chest expansion
acute chest pain, severe dyspnea and cyanosis, acute RVF—all of this post-op, what is the most likely diagnosis?
massive post operative lung collapse
