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Respiratory Emergencies 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
What kind of breathing is common above 9000 ft?
Cheyne-Stokes breathing
26
Sxs of acute mountain sickness?
lightheadedness/dizziness HA- bifrontal worse with bending over or valsalva anorexia, nausea weakness, irritability
27
PE findings in patient with acute mountain sickness?
+/- postural hypotension localized rales retinal hemorrhages fluid retention**
28
Pathophys of acute mountain sickness?
due to hypobaric hypoxia cerebral blood increases > brain enlarges > vasogenic edema develops
29
Tx for acute mountain sickness?
stop ascending! Go back down to lower elevation Oxygen Acetazolamide high dose: ASA or Tylenol or Motrin (600-800mg) Dexamethasone 4mg Q6hrs
30
How can you prevent acute mountain sickness?
ascend gradually avoid overexertion, alcohol or respiratory depressants eat high carb meals (yummm) Acetazolamide 24hrs before ascent Dexamethasone
31
Presentation of high altitude cerebral edema?
Acute mountain sickness (AMS) with neuro sxs - Ataxia - Stupor - Coma - CN palsy 3, 6
32
Tx for high altitude cerebral edema?
O2 descent/evacuation Dexamethasone Loop diuretics: Furosemide. Bumetanide
33
What is the most lethal of the high altitude illnesses?
high altitude pulmonary edema
34
Sxs of high altitude pulmonary edema?
dry cough, later progresses to productive decreased exercise performance rales, dyspnea coma, death
35
what causes high altitude pulmonary edema?
due to high pulmonary microvascular pressures and development of pulmonary HTN
36
Tx for high altitude pulmonary edema?
immediate descent O2 > may take 72 hrs to resolve Nifedipine 20 mg Q8hrs
37
s/s of CHF
hypoxemia, HTN, tachycardia, dyspnea, weight gain, rales
38
Sxs left sided HF? right?
dyspnea, fatigue, cough, PND, orthopnea peripheral edema, JVD, RUQ pain
39
CHF work up should include....
``` CBC- anemia Chemistries- electrolytes, renal fun. Cardiac enzymes Pro-BMP EKG CXR -b lines, cardiomegaly, etc. Echo ```
40
BNP over....suggests HF
200
41
Tx for CHF?
o2 and ventilation Nitro-reduces preload and BP Morphine Sulfate Diuretic- furosemide. Bumetanide Dobutamine
42
What drugs should you AVOID in pts presenting with CHF?
CCB > cause pulmonary edema and cardiogenic shock NSAIDS > inhibit effects of diuretics anti-arrhythmics
43
What's virchow's triad?
Risk for PE/DVT - Venous stasis - Vessel wall inflammation - hypercoagulability
44
s/s of PE
dyspnea, pleuritic CP, syncope, LE pain/swelling, confusion/anxiety, hypoxemia TRIAD: pleuritic CP, SOB, hemoptysis
45
What can we use for risk assessment of PE/DVT?
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
Interpretation of wells score?
0-1 low risk 3.6% chance 2-6 moderate 20.5% chance >6 high 66.7% chance
47
What can you use to r/o PE?
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
CXR for PE?
1/3 normal +/- Hampton's hump: triangular pleural based infiltrate Westermark's sign* Feischner sign
49
What tests can you check for PE?
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
What does D-dimer measure?
fibrin degradation products, lots of things elevate this!
51
EKG in PE?
MC finding: sinus tachycardia specific: S1Q3T3
52
Tx for PE?
Heparin if/when in the hospital then one of the following: - Coumadin - Lovenox - Rivaroxaban (Xarelto)
53
Indications for thrombolytic tx for PE? contraindications?
massive PE, hemodynamically unstable massive iliofemoral DVT large DVT with sig. vascular compromise contraindications: bleeding risks, uncontrolled HTN, pregnancy
54
Thrombolytic agents for PE? other options?
Streptokinase Urokinase Alteplase (Activase) tPA-only one with FDA approval Mechanical: embolectomy, catheter directed thrombolysis
55
What is asthma? Pathophys triad?
chronic (but reversible) inflammatory disorder Airway inflammation Obstruction to airflow Bronchial hyperesponsiveness
56
Clinical triad for asthma?
dyspnea, wheezing, cough
57
Describe COPD
chronic irreversible disorder includes: chronic bronchitis and emphysema
58
S/S of COPD?
cough- usually worse in the AM SOB wheezing tachypnea cyanosis
59
What can we use to assess COPD?
FEV1 pulse ox CXR blood tests- not usually indicated
60
Cornerstone of obstructive airway therapy?
beta agonist corticosteroids- for exacerbations
61
What is the best method for delivery of beta agonist? MDI v. nebulizer? Intermittent v. continuous?
equal efficacy- must use spacer/chamber device with MDI continuous reserved for severe exacerbations q
62
How is epinephrine used in obstructive airway disease?
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
Ipratropium Bromide MOA? When is this used?
Blocks cholinergic stimulation of airway smooth muscle Works primarily on large central airways Should be given in conjunction with beta agonist
64
MOA of corticosteroids?
reduce inflammation and upregulate B receptors
65
When is magnesium sulfate used?
For severe asthma exacerbations-haven't responded to multiple txs inhibits smooth muscle action potential leading to bronchodilation
66
What are some other options for asthma exacerbations?
Heliox- reserved for severe rxns (peds) Theophylline Ketamine BiPAP
67
Peak age occurrence for FB aspiration?
btwn 1-3 yrs old second peak at 85 yrs of age
68
Presentation of FB aspiration?
depends on size and location of FB Cough > acute airway obstruction Stridor > laryngotracheal FB wheezing > bronchial FB universal chocking sign
69
What should be considered in all children with unilateral wheezing and persistent symptoms that do not respond to bronchodilators?
FB aspiration
70
Dx of FB aspiration?
CXR- often no helpful, hyperexpansion of unilateral lung field CT Laryngoscopy and/ror bronchoscopy
71
Common locations for FB?
MC- thoracic inlet, at level of clavicles on CXR mid esophagus distal esophagus
72
If coin appears turned to the side on AP CXR it is likely in the...
esophagus
73
What should you do for an conscious patient who you suspect was chocking?
CPR NO blind finger sweep
74
What's the difference btwn stridor and wheezing?
Stridor: Inspiratory sound, Upper airway Wheezing: Expiratory sound, lower airway
75
What is the clinical significance of head bobbing and see saw breathing?
both are signs of impending respiratory failure
76
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?
Legionella Azithromycin
77
What is the treatment of choice for high altitude pulmonary edema?
immediate descent
78
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?
Standard histories, including HPI IV, oxygen, monitor IV fluids (NS or LR) Chest x-ray
79
What can give you a false positive d-dimer? What can give you a false negative?
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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