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Clinical Disciplines- Emergency Medicine > Respiratory Emergencies > Flashcards

Respiratory Emergencies Flashcards

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Royal College: Emergency Medicine flashcards
1
Q

Define hypoxemia

A

Abnormally low arterial oxygen tension

PaO2 <60mmHg

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2
Q

What causes hypoxemia?

A

Hypoventilation-causes increased PaCO2

Right to left shunt

Ventilation-Perfusion mismatch

Diffusion

Low inspired air

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3
Q

What is a hallmark of right to left shunt?

A

failure to increase oxygen levels with supplemental oxygen

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4
Q

Where is stridor hear? What can cause this?

A

upper airway, inspiratory

FB, croup, epiglottis, anaphylaxis

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5
Q

Where is wheezing heard? What can cause this?

A

lower airway, expiratory

Asthma, COPD, FB, cardiogenic pulmonary edema

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6
Q

Where are rales heard? What causes this?

A

lower airway

sounds like velcro being pulled apart

CHF

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7
Q

Where is rhonchi heard? What causes this?

A

lower airway

pneumonia

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8
Q

What are the symptoms of hypoxia? (early and late)

A

Early RAT:

  • restlessness
  • anxiety
  • tachycardia/tachypnea

is late to BED

  • bradycardia
  • extreme restlessness
  • dyspnea
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9
Q

When are head bobbing and see saw breathing seen?

A

in respiratory distress or failure

see saw- using abd muscles for breathing

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10
Q

Describe pna

A

obstruction of bronchioles

decreased gas exchange, increased exudate

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11
Q

What is the pna triad?

A

fever, dyspnea, cough

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12
Q

Name the pathogen based pna sputum:

  • rust colored…
  • green colored..
  • red currant jelly..
  • foul smelling or bad tasting
A

s. pneumoniae

pseudomonas, Heamophilus

klebsiella

anaerobes

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13
Q

Pt with sxs suggestive of pna…the following additional symptoms makes you concerned that it is do to which pathogens?

  1. bradycardia and hyponatremia
  2. Bullous myringitis
A

Legionella

mycoplasma pneumoniae

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14
Q

Risk factors for aspiration pna?

A

poor cough, poor gag reflex, impaired swallowing, GI dysmotility, alcoholism, CNS depression

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15
Q

MCC of pna is S. Pneumoniae, what are the typical presenting sxs?

A

sudden onset fever, rigors, productive cough, dyspnea

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16
Q

Klebsiella pna is common in?

A

alcoholics, NH pts

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17
Q

Work up for pna?

A 
CXR, CT 
CBC 
Chemistries 
ABG 
Blood cultures 
Lactic acid (if high think sepsis)
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18
Q

Therapy for pna may include?

A 
IV fluids 
antipyretics 
oxygen 
bronchodilator 
abx 
cough suppressant with expectorant 
steroids
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19
Q

Abx for HCAP

A

Cefepime or Ceftazidime or Piperacillin-tazobactam

+Ciprofloxacin or Levofloxacin

+Vancomycin

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20
Q

What is CURB 65 used for? What is included in this?

A

pna mortality predictor

Confusion 
Uremia (BUM >20) 
RR >30 breaths per minute 
Blood pressure <90 or SBP <60
Age over 65 yrs

0-1 outpt
2-admit
3-5 ICU

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21
Q

High altitude is a….

A

hypoxic environment

oxygen concentration remains constant

most pronounced during sleep

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22
Q

How do our bodies acclimate to high altitude?

A

hypoxic ventilatory response:
-carotid body senses decrease in arterial o2

  • stimulates medulla to increased ventilation rate
  • HR increases
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23
Q

What does Actezolamide cause?

A

bicarbonate diuresis

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24
Q

What happens to blood at high altitude? fluid?

A

erythropoietin increases in plasma

peripheral venoconstriciton increases central blood volume, ADH & aldosterone suppressed >diuresis

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25
Q

What kind of breathing is common above 9000 ft?

A

Cheyne-Stokes breathing

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26
Q

Sxs of acute mountain sickness?

A

lightheadedness/dizziness

HA- bifrontal worse with bending over or valsalva

anorexia, nausea

weakness, irritability

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27
Q

PE findings in patient with acute mountain sickness?

A

+/- postural hypotension

localized rales

retinal hemorrhages

fluid retention**

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28
Q

Pathophys of acute mountain sickness?

A

due to hypobaric hypoxia

cerebral blood increases > brain enlarges > vasogenic edema develops

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29
Q

Tx for acute mountain sickness?

A

stop ascending! Go back down to lower elevation

Oxygen

Acetazolamide

high dose: ASA or Tylenol or Motrin (600-800mg)

Dexamethasone 4mg Q6hrs

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30
Q

How can you prevent acute mountain sickness?

A

ascend gradually

avoid overexertion, alcohol or respiratory depressants

eat high carb meals (yummm)

Acetazolamide 24hrs before ascent

Dexamethasone

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31
Q

Presentation of high altitude cerebral edema?

A

Acute mountain sickness (AMS) with neuro sxs

  • Ataxia
  • Stupor
  • Coma
  • CN palsy 3, 6
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32
Q

Tx for high altitude cerebral edema?

A

O2

descent/evacuation

Dexamethasone

Loop diuretics: Furosemide. Bumetanide

33
Q

What is the most lethal of the high altitude illnesses?

A

high altitude pulmonary edema

34
Q

Sxs of high altitude pulmonary edema?

A

dry cough, later progresses to productive

decreased exercise performance

rales, dyspnea

coma, death

35
Q

what causes high altitude pulmonary edema?

A

due to high pulmonary microvascular pressures and development of pulmonary HTN

36
Q

Tx for high altitude pulmonary edema?

A

immediate descent

O2 > may take 72 hrs to resolve

Nifedipine 20 mg Q8hrs

37
Q

s/s of CHF

A

hypoxemia, HTN, tachycardia, dyspnea, weight gain, rales

38
Q

Sxs left sided HF?

right?

A

dyspnea, fatigue, cough, PND, orthopnea

peripheral edema, JVD, RUQ pain

39
Q

CHF work up should include….

A 
CBC- anemia 
Chemistries- electrolytes, renal fun. 
Cardiac enzymes 
Pro-BMP 
EKG 
CXR -b lines, cardiomegaly, etc. 
Echo
40
Q

BNP over….suggests HF

A

200

41
Q

Tx for CHF?

A

o2 and ventilation

Nitro-reduces preload and BP

Morphine Sulfate

Diuretic- furosemide. Bumetanide

Dobutamine

42
Q

What drugs should you AVOID in pts presenting with CHF?

A

CCB > cause pulmonary edema and cardiogenic shock

NSAIDS > inhibit effects of diuretics

anti-arrhythmics

43
Q

What’s virchow’s triad?

A

Risk for PE/DVT

  • Venous stasis
  • Vessel wall inflammation
  • hypercoagulability
44
Q

s/s of PE

A

dyspnea, pleuritic CP, syncope, LE pain/swelling, confusion/anxiety, hypoxemia

TRIAD: pleuritic CP, SOB, hemoptysis

45
Q

What can we use for risk assessment of PE/DVT?

A

Wells Score:

3 - Suspected DVT
3 – Alternative diagnosis less likely than PE*
1.5 – Heart rate >100bpm
1.5 – Immobilization or surgery within previous 4 weeks
1.5 – Previous DVT/PE
1 – Hemoptysis
1 – Malignancy

46
Q

Interpretation of wells score?

A

0-1 low risk 3.6% chance

2-6 moderate 20.5% chance

> 6 high 66.7% chance

47
Q

What can you use to r/o PE?

A

PERC criteria:

Age <50 years old
Pulse oximetry >94% on room air
Heart rate <100 bpm
No prior venous thromboembolism
No recent surgery or trauma within prior 4 weeks
Requiring hospitalization, intubation, epidural anesthesia
No hemoptysis
No estrogen use
No unilateral leg swelling

if all YES, risk is less that 2%

48
Q

CXR for PE?

A

1/3 normal

+/-
Hampton’s hump: triangular pleural based infiltrate

Westermark’s sign*

Feischner sign

49
Q

What tests can you check for PE?

A

CT** test of choice

CXR

V/Q scan- normal perfusion can exclude PE

Echo- not really used

venous compression US- for LE

ABGs- 75% room air hypoxia, 65% widened A-a gradient

D-dimer

May have elevated: pro-BNP, Trop

50
Q

What does D-dimer measure?

A

fibrin degradation products, lots of things elevate this!

51
Q

EKG in PE?

A

MC finding: sinus tachycardia

specific: S1Q3T3

52
Q

Tx for PE?

A

Heparin if/when in the hospital

then one of the following:

  • Coumadin
  • Lovenox
  • Rivaroxaban (Xarelto)
53
Q

Indications for thrombolytic tx for PE? contraindications?

A

massive PE, hemodynamically unstable

massive iliofemoral DVT

large DVT with sig. vascular compromise

contraindications: bleeding risks, uncontrolled HTN, pregnancy

54
Q

Thrombolytic agents for PE? other options?

A

Streptokinase

Urokinase

Alteplase (Activase) tPA-only one with FDA approval

Mechanical: embolectomy, catheter directed thrombolysis

55
Q

What is asthma? Pathophys triad?

A

chronic (but reversible) inflammatory disorder

Airway inflammation

Obstruction to airflow

Bronchial
hyperesponsiveness

56
Q

Clinical triad for asthma?

A

dyspnea, wheezing, cough

57
Q

Describe COPD

A

chronic irreversible disorder

includes: chronic bronchitis and emphysema

58
Q

S/S of COPD?

A

cough- usually worse in the AM

SOB
wheezing
tachypnea
cyanosis

59
Q

What can we use to assess COPD?

A

FEV1

pulse ox

CXR

blood tests- not usually indicated

60
Q

Cornerstone of obstructive airway therapy?

A

beta agonist

corticosteroids- for exacerbations

61
Q

What is the best method for delivery of beta agonist? MDI v. nebulizer? Intermittent v. continuous?

A

equal efficacy- must use spacer/chamber device with MDI

continuous reserved for severe exacerbations q

62
Q

How is epinephrine used in obstructive airway disease?

A

Acts as bronchodilator but is NOT beta selective

no benefit over albuterol, Don’t give IV epi unless in code (makes heart beat too fast)

63
Q

Ipratropium Bromide MOA? When is this used?

A

Blocks cholinergic stimulation of airway smooth muscle

Works primarily on large central airways

Should be given in conjunction with beta agonist

64
Q

MOA of corticosteroids?

A

reduce inflammation and upregulate B receptors

65
Q

When is magnesium sulfate used?

A

For severe asthma exacerbations-haven’t responded to multiple txs

inhibits smooth muscle action potential leading to bronchodilation

66
Q

What are some other options for asthma exacerbations?

A

Heliox- reserved for severe rxns (peds)

Theophylline

Ketamine

BiPAP

67
Q

Peak age occurrence for FB aspiration?

A

btwn 1-3 yrs old

second peak at 85 yrs of age

68
Q

Presentation of FB aspiration?

A

depends on size and location of FB

Cough > acute airway obstruction

Stridor > laryngotracheal FB

wheezing > bronchial FB

universal chocking sign

69
Q

What should be considered in all children with unilateral wheezing and persistent symptoms that do not respond to bronchodilators?

A

FB aspiration

70
Q

Dx of FB aspiration?

A

CXR- often no helpful, hyperexpansion of unilateral lung field

CT

Laryngoscopy and/ror bronchoscopy

71
Q

Common locations for FB?

A

MC- thoracic inlet, at level of clavicles on CXR

mid esophagus

distal esophagus

72
Q

If coin appears turned to the side on AP CXR it is likely in the…

A

esophagus

73
Q

What should you do for an conscious patient who you suspect was chocking?

A

CPR

NO blind finger sweep

74
Q

What’s the difference btwn stridor and wheezing?

A

Stridor: Inspiratory sound,
Upper airway

Wheezing: Expiratory sound, lower airway

75
Q

What is the clinical significance of head bobbing and see saw breathing?

A

both are signs of impending respiratory failure

76
Q

Your patient presents for evaluation of an elevated temperature and productive cough. 134/80, 50, 24, 102.4, 92% RA. Labs are significant for leukocytosis of 16k and sodium of 127. Based on this presentation, what etiologic agent do you suspect?

How do you treat it?

A

Legionella

Azithromycin

77
Q

What is the treatment of choice for high altitude pulmonary edema?

A

immediate descent

78
Q

You are evaluating a 56 year old male with history of colon cancer, on chemotherapy, who presents for evaluation of shortness of breath. 90/40, 123, 28, 87% RA, 101.1. How do you proceed?

A

Standard histories, including HPI

IV, oxygen, monitor

IV fluids (NS or LR)

Chest x-ray

79
Q

What can give you a false positive d-dimer? What can give you a false negative?

A

cancer, inflammation, infection, aging (>70 yrs), recent surgery, trauma, MI, pregnancy, arterial thrombosis, acute CVA, superficial phlebitis, RA, liver disease

warfarin, symptoms <5 days, small clot burden

Clinical Disciplines- Emergency Medicine (3 decks)

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