Respiratory Emergencies 2 Flashcards
Tx for High Altitude Cerebral Edema
4 things
- Oxygen
- Descent/Evacuation
- Dexamethasone
-
Loop Diuretics
- Furosemide
- Bumetanide
What is the most lethal of the high altitude illnesses?
High Altitude Pulmonary Edema
Which condition?
- Dry cough, progresses to productive cough
- Decreased exercise performance / increased recovery time from exercise
- Rales - increased after exercise
- Increasing dyspnea
- Coma, death
High Altitude Pulmonary Edema
High Altitude Pulmonary Edema
- Is due to high ___ ___ _____ & development of pulmonary HTN
pulmonary microvascular pressures
Tx for High Altitude Pulmonary Edema
- Recognition
- Immediate descent is tx of choice
- Oxygen, may take up to ___ hours to resolve HAPE
- ____ every 8 hours
- 72 hours
- Nifedipine
What is the most common reason for admission in Medicare pts?
CHF
Most common cause of CHF?
LV dysfunction
4 cardiac issues associated w/ CHF?
- Aortic stenosis
- Hypertension
- A. fib
- Coronary artery disease
Signs / Sxs of what?
- Hypoxemia
- HTN
- Tachycardia
- Dyspnea
- Weight gein
- Rales
CHF
Sxs of left or right CHF?
- Dyspnea
- Fatigue
- Cough
- PND
- Orthopnea
Left
Sxs of left or right CHF?
- Peripheral edema
- JVD
- RUQ pain
Right
Testing for CHF (5)
- CBC (anemia)
- Chemistries (electrolytes / renal function)
- Cardiac enzymes
- Pro-BNP (released by ventricular myocardium in response to stretching) >200 suggests CHF
- EKG
(PECCC)
Chest x-ray for CHF has high or low sensitivity?
- Dilated upper lobe vessels
- Cardiomegaly
- Interstitial edema
- Enlarged pulmonary artery
- Pleural effusions
- Kerley B lines
Low
What has a higher sensitivity / specificity compared to CXR for diagnosing CHF?
US of lung will show B lines
CHF
What dx test is used to evaluate LV and valvular functions, tamponade, VSD?
Echocardiography
3rd leading cause of death of hospitalized pts in the US
PE
Most common cause of non-surgical maternal deathin peripartum period is what?
PE
PE occurs when proximal portion of ______ breaks off and travels to lung
Most commonly due to ___ or _____ veins, but can result from any vain (except intracranial veins)
- venous thrombosis
- pelvic or deep lower extremity
Virchow’s Triad of PE
- Venous stasis
- Vessel wall inflammation
- Hypercoagulability
Risk Factors of PEs
(moist camels)
- Malignancy
- Obesity
- Immobilization
- Surgery
- Trauma
- CHF
- Age >40
- Mobility (lack of)
- Estrogen excess
- Long bone fx
- Smoker
Triad of sxs of PE
- Pleuritic CP
- SOB
Hemoptysis
Wells Score is used for what?
Risk Assessment of PE
Besides Wells Score, what are 2 other Risk Assessment tools for PE?
- Simplified Revised Geneva Score
- PERC Criteria
If all answers are “yes” for PERC criteria the risk of PE is _____.
Less than 2%
Is “Experiences Clinical Gestalt” better or worse at assessing risk of PE compared to the tools?
Just as well
3 CXR signs for PE
(CXR is normal 1/3 of the time)
- Hampton’s Hump (triangular pleural based infiltrate w/ apex pointed toward hilum)
- Westermark’s sign (dilate pulmonary vessels proximal to embolus w/ sharply demarcated cutoff)
- Fleischner sign (distended central pulmonary artery)
What is the diagnostic test of choice for PE? Why?
CT scan
- Good at identifying central clots, but can miss small peripheral clots
- Also identifies other possible causes
- Iodine infusion required
What is seen on electrocardiography if pt has large clot (PE) (likely central) w/ poor prognosis?
RV enlargment & RV dysfunction
What US is used to evaluate primarily the lower extremities from groin distally?
Venous Compression US
What test cannot be used to exclude / diagnose PE?
ABG
ABG
- PAO2 =?
- PaO2 =?
- PAO2 = partial pressure of oxygen in alveolus
- PaO2 = partial pressure of oxygen in artery
- What test for PE measures fibrin degradation products?
- Is detectable within __ hour(s) of thrombus formation
- Has high negative predictive value, but poor positive predictive value
- D Dimer
- 1
Value is increased with:
- Cancer
- Inflammation
- Infection
- Aging >70
- Recent surgery
- trauma
- MI
- pregnancy
- arterial thrombosis
- acute CVA
- Superficial phlebitis
- RA
- Liver disease
D dimer
Value decreased with:
- Warfarin
- Sxs <5 days
- Small clot burden
What blood tests can be elevated w/ PE?
Pro-BNP
Troponin
- What is the most common EKG finding for PE?
- Followed by what?
- What EKG finding represents right heart strain and is seen in only 20% of cases?
- Sinus Tachycardia
- T wave inversions
- S1Q3T3
Tx for PE?
- Heparin, must monitor PTT
- Coumadin, must monitor PT/INR
- Lovenox
- Rivaroxaban (Factor Xa inhibitor)
- Vena caval filter if problem or contraindications to anticoagualation
3 indications for Thrombolytic Tx of PE?
- Massive PE (hemodynamically unstable)
- Massive ileofemoral DVT
- Large DVT w/ significant vascular compromise
Contraindications for Thrombolytic Tx of PEs
- Major bleeding within 6 months
- Intracranial or intraspinal surgery / trauma within 2 months
- Surgery within 10 days
- Pericarditis/Endocarditis
- Uncontrolled HTN
- Pregnancy
- Suspected aneurysm
(MISPUPS)
3 Thrombolytic Agents
- Streptokinase (highly antigenic)
- Urokinase
- Alteplase
2 mechanical treatments for PE
- Embolectomy (for massive PEs if pt has contraindications to fibrinolysis/unstable after fibrinolysis)
- Catheter directed thrombolysis (Alteplase infused over 4 hours)
- Chronic/reversible inflammatory disorder affecting 10% of adults and 30% of children
Asthma
Pathophysiology triad of asthma
- Airway inflammation
- Obstruction to airflow
- Bronchial hyper-responsiveness
Clinical triad of asthma
- Dsypnea
- Wheezing
- Cough
Chronic / Irreversible Disorder
COPD
- Chronic Bronchitis
- Emphysema
Chronic Bronchitis or Emphysema?
- Presence of chronic productive cough for 3 months in 2 successive years
- Clinical dx
Chronic Bronchitis
Chronic Bronchitis or Emphysema?
- Destruction of bronchioles and alveoli
- Pathologic dx
Emphysema
Most common risk factor (90%) for COPD?
Tobacco use
(only 15% of tobacco smokers develop COPD)
Besides smoking, what are 4 other risk factors for COPD?
- Occupational exposures
- Environmental exposures (air pollution)
- Alpha 1 antitrypsin deficiency
- IVDA
What is used to assess COPD and is patient dependent?
- Measures severity of airway restriction
- Should be compared to pt’s baseline
- Can be used to monitor response to therapy
- Use guidelines if age/height table not available
FEV1
3 tx goals of COPD
- Reverse airflow obstruction
- Provide adequate oxygenation
- Relieve inflammation
