Respiratory Emergencies Flashcards
Components of good quality X-ray
•Rotation- identify if spine is center and straight. Clavicle should line up as well
•Inspiration- did they take a deep breath and hold it. Count anterior ribs. 5-7 need to line up with diaphragm at the mid-clavicular line.
*anterior ribs are swooping down and in
•Penetration- should be able to see the spinus processes through the heart
PA vs AP X-ray view
Posterior/Anterior view vs Anterior/Posterior view
• PA view is Preferred route if chest X-ray
•AP view will exaggerate the the size of the heart
• most patients end up getting an AP view because they are in bed and can’t stand up.
What do bone and air filled spaces look like in an X-ray
•Bone or solid things appear more white
•Air filled spaces look more dark
What is consolidation
A region of normally compressible lung tissue that has filled with liquid instead of air
Hilar point
Area of the lung where all the vessels are coming out from the center. Left Hilar point will be a little higher up than the right due to the hearts position in the chest cavity
*should be able to see congestion in these areas
Chronic Bronchitis
•Excessive mucus production
•Airway obstruction
•Hypoxemia, polycythemia, and increased CO2 retention occurs
•These individuals have signs of R heart failure(exurtional dyspnea, cor pulmonal, fatigue, tachypnea)
•Known as blue bloaters
Emphysema
• destruction of airways
• destruction of pulmonary capillary beds
• V/Q mismatch
• Muscle wasting
• Considered pink puffers
• decrease in surface area in alveolar membranes
COPD Tx
•stop smoking
•bronchodilator (short and long acting)
•Anticholinergic drugs(Ipratropium, atropine)
•Phosphodiesterase inhibitors(help bronchodilation, improves contractility of diaphragm, and increase stimulation in respiratory center in the brain) *Theoflen, airflow
•Corticosteroids-decrease airway inflammation and reduce airway edema by reducing immune response
•Mucolytic agents(musinex)- thin secretions and help move them out.
Abnormal Chest X-ray(CXR)
•Flattened diaphragm
•increased AP diameter of the chest (lateral view)
•long narrow heart
•abnormal air collections in the lung(bullae)
Asthma info
•Complex patho
•Many different causes
•may have increased breath sounds on exhalation
•beware of the SILENT CHEST(no air movement)
•Pulsus paradoxus may be present(not the only situation you can see this in) -abnormal decrease in BP on inspiration(<10mm/hg)
•How to check for pulsus paradoxus-#1auscultate heart while palating radial pulse. You should hear the beat but not feel the pulse.
#2 look at amplitude on ECG. If the amplitude decreases during inhalation and then returns to baseline, positive for pulsus paradoxus.
Asthma Tx
• bronchodilators
• anticholingerics (ipratropium)
•corticosteroids
•heliox(helium-oxygen mixture. 80:20 or 70:30 ratio.
•Intubation is last resort!
• Ketamine is a bronchodilator so use K if possible/needed.
ARDS info
•Caused by an acute accumulation of inflammatory mediators and neutrophils
•Diffuse alveolar damage and lung capillary endothelial injury
•Associated with increased pulmonary vascular permeability
•Increased dead space
•Decreased lung compliance
•fluid build up in the interstitial space causes gas exchange to be more difficult
•Most diagnoses are not true ARDS and most cases are iatrogenic.
•Iatrogenic factors: volume overload, effusions, atelectasis.
•use PEEP
Causes of ARDS(direct lung injury)
•Pneumonia(most common)
•aspiration
•near drowning
•inhalation injury
•pulmonary contusion
•pulmonary edema from reperfusion therapy
Causes of ARDS(indirect lung injury)
2 most common:
•Sepsis
•Trauma from shock
Other causes:
•CABG
•OD
•Blood product admin
•acute pancreatitis
ARDS X-ray findings
•Rapid deterioration
•bilateral
•patchy or ground glass”hazy” areas
•pleural effusions
ARDS Tx
•Tx underlying cause
•Supportive care(strict I/O)
•Noninvasive or mechanical ventilation
-lower Vt, lung protective, high PEEP & FIO2
-(APRV) Airway pressure release ventilation
• early admin of antibiotics
**conservative volume resuscitation(don’t volume overload) vasopressors instead of fluid!!!
Pneumonia
•Inflammation/infection
•Consolidation of affected area
•CXR findings: Consolidation(white) and Opacities
Pneumonia Tx
•Antibacterial Tx within 4 hrs of admission
•Bronchodilators
•Oxygen
•CPAP/Ventilator support if needed
•Fluid resuscitation (be cautious, don’t fluid overload)
•supportive care
Tension Pneumothorax on CXR
•If you see vascular markings then the lung is not deflated completely. If you don’t have vascular markings, the lung is deflated.
•Shifting of trachea and mediastinum(late signs)
•if you see the outlining of the pleura, it’s partially deflated.
ARDS definition
AECC:
•Acute onset
•bilateral infiltrates
•pulmonary artery wedge pressure <18mmHg
•PaO2/FIO2 ratio <200 = ARDS
•PaO2/FIO2 ratio <300 = acute lung injury(ALI)
Correct NGT position
•NGT tip >10cm distal to the gastroesophageal junction(where it turns and goes into stomach)
•below the left hemidiaphragm
•ask to look at X-ray to confirm before using equipment.
ETT position
•ETT tip 5cm +/- 2cm above the carina
•at the level of the medial ends of the clavicles
Central venous catheter(CVC)
•Right side: 1-1.5cm above the level of the carina
•Left side: below the level of the carina
Chest tube position
•5th intercostal, mid-axillary
•for pneumothorax, the tube tip is positioned upper pleural cavity
•for pleural effusion, the tube tip is positioned lower pleural cavity
PE info
•Venous thromboembolism complication
•symptoms: tachycardia/tachypnea, Rales, diaphoresis, S3 or S4 gallop, cardiac murmur, CP, maybe syncope.
•EKG changes: S1 Q3 T3, tachycardia, RBBB, T wave inversion in V1-V4 and sometimes inferior, RA enlarged-P-wave >2.5mm in lead 2.
•gas exchange issues: v/Q mismatch, decreased PaO2, right to left shunt, increased total dead space, respiratory alkalosis.
•they will not be hypercapneic
PE Tx
•Hemodynamic Tx
—be cautious with sedatives and volume. Early vasopressors is best if hypotensive
•Immediate anticoagulation
•Thrombolytic therapy
•Surgery/filter placement
Quick question:
What is the secondary complication to COPD?
Answer:
Polycythemia
Possibly a reaction to chronically low oxygen levels
Quiz question:
What best describes pulmonary embolus
Answer:
Causes increased alveolar dead space.
Alveolar dead space occurs with no perfusion, but continued ventilation. An intra-pulmonary shunt would occur when there is no perfusion or ventilation. A pulmonary embolus will cause the patient to hyperventilate, causing the patient to become very fatigued.
Quick question:
What is the leading indirect cause of ARDS?
Answer:
Shock
Specifically septic shock, because blood is shunted away from the longest to the heart and brain to maintain essential organ function. Shock also triggers, the systemic, inflammatory response, cascade, which will increase the permeability of the alveolar capillary membrane.
Quick question:
How far past the gastroesophageal junction should the tip of an NGT be located?
Answer:
At least 10 cm
Quick question:
Why would you intubate a near drowning patient with these ABGs?
pH 7.32, PaCO2 48, PaO2 46, HCO3- 20?
Answer:
The patient is suffering from a mixed disturbance with associated hypoxia. The patient needs to be evaluated for intubation and mechanical ventilation based on the near journey incident. Further care would consist of CPAP or NIPPV and potential intubation.
Quick question:
Reasons and acute asthma exacerbation would need intubation
Answer:
Decline in level of consciousness, hypo ventilation, secondary to muscle fatigue, and uncompensated respiratory acidosis.
Uncompensated respiratory acidosis will lead to muscle fatigue, which will lead to hypo ventilation, which will lead to respiratory failure.
Quick question:
What is the most common cause of diminished breath sounds after surgery especially in smokers
Answer:
Atelectasis
