Respiratory Emergencies Flashcards
Dyspnea Definition
Subjective feeling of difficult, labored, or uncomfortable breathing
Tachypnea Definition
Rapid breathing
Normal varies by age
Bradypnea Definition
Slow breathing
Orthopnea Definition
Dyspnea in recumbent position
MC in CHF
Paroxysmal nocturnal dyspnea definition
Dyspnea that awakens pt from sleep
Hypoxia Definition
Insufficient delivery of O2 to tissues.
SaO2 < 94% on Room Air
Hypoxemia (Blood Gas)
Abnormally low arterial O2 tension
PaO2 < 60mmHg
Causes of Hypoxemia
Hypoventilation-increased PaCo2
Right-2-Left shunt: hallmark = failure to increase O2 levels with supplemental O2
V:Q mismatch
Diffusion
Low inspired O2 (high altitudes)
Stridor
Upper Airway
Inspiratory
Foreign body, croup, epiglottis
Anaphylaxis
Wheezing
Lower Airway
Expiratory
Asthma, COPD, foreign body, cariogenic pulmonary edema
Rales
Lower airway
Sounds like velcro pulled apart
CHF
Ronchi/crackles
Lower airway
PNA
Symptoms of Hypoxia
Early:
Restlessness
Anxiety
Tachycardia/pnea
Late:
Bradycardia
Extreme Restlessness
Dyspnea
Peds: Feeding difficulty Inspiratory stridor Nares Flare Expiratory Grunt Sternal retracting
Respiratory distress or failure
Inadequate O2 and/or vent
Signs: Tachypnea/bradypnea, retractions, nasal false, head bobbing (up for inhale, down for exhale), pre-arrest, AMS, See-saw breathing (abd muscles) hypoxia
Grunting = late
PNA
Infection of alveoli
Triad: FEVER, DYSPNEA, COUGH
Sputum: Rust = Step PNA (MC) Green = Pseudo, Haemophilus Red currant: Klebsiella Foul-smelling or bad-test: anaerobes
Signs/symp:
brady/hypoNa: legionella
Bulls myringitis: myco PNA
CAP vs HAP vs VAP
CAP: pt no hospitalized/resident of LTC x 14 days prior
HAP (nosocomial): > 48hr post-admit
VAP: PNA > 48 hr post-intubate
Healthcare-associated
pt hospitalized > 2d last 90d NH resident IV ABX HD Chronic Wounds Chemo Immunocomprosmised
Aspiration PNA
Inhalation of oropharyngeal secretion
Risk increased: poor cough (muscle weakness) poor gag reflex Impaired swallow GI dysmotility ETOH CNS depression
Streptococcus PNA
MCC PNA
symptoms: sudden fever, rigors, productive cough, dyspnea
Risks: elderly, <2y.o
minorities
Day care
Underlying medical conditions
Lobar infiltrate
para-PNA pleural effusion (around infiltrate)
Lobar Infiltrates on CXR
Heart edge = RML
Upper, no touch: RUL
Lower, Heart border intact: RLL
If on L and hits heart: LUL (lingular)
Staph Aureus PNA
Common following viral
CXR shows extensive infiltrates (Cavitations)
Klebsiella PNA population
Common in ETOH, NH its
PNA diagnostic testing
CXR, CT (CT tech better) CBC Chems ABG Blood cultures (req'd if you admit) Lactic Acid (measures if tissues getting enough NTR/O2; also treatment measure)
PNA Therapy
IVF (NS/LR) Antipyretics (HR incr 10 /1degree over normal) O2 Bronchodilator Abx Cough Suppressant w/ expectorant Steroids
HCAP Abx
Cefepime Ceftazidime Piperacillin-Tazobactam Ciprofloxacin Levofloaxin Vancomycin
CURB 65
Mortality Predictor Confusion Uremia (BUN>20) Resp Rate > 30 br/min BP < 90mmHg sys/60mmHg dia Age > 65
0-1 OP
2 admit
3-5 ICU
High Altitude Illness
Partial Pressure of O2 decr as barometric pressure changes
elevates >5000ft (MC 8-14K)
Most pronounced during sleep
Most critical: sleeping altitude and rate of ascent
Altitude Acclimation (ventilation response)
- Carotid body senses decr in art O2
- Stimulates medulla to incr. vent rate (resp alka)
- Response lessened by rest depressants, chronic hypoxia
- Acetazolamide causes bicarb diuresis
Altitude Acclimation (blood)
Erythropoietin increased in plasma
Increases RBC mass
Starts as early as 2 hours after ascent
Altitude Acclimation (fluid)
Peripheral venoconstriction increases central blood volume
ADH and aldosterone suppressed causes diuresis
Altitude Acclimatization (CVD)
HR incr. to compensate for decr stroke volume
Max exercise HR decr
Pull vessels constrict
Cerebral blood flow increases
Altitude Acclimatization (sleep)
Cheyne-Stokes breathing common > 9000 ft
Acute Mountain Sicknesss
Si/sx: lightheaded, dizzy, H/a (bifrontal, incr bending over/valsalva), breathlessness w/ activity, anorexia, Nausea, weakness, irritability
Findings: postural Hypotension, rales up to 20% retinal hemorrhages, FLUID RETENTION (decr urination)
Acute mountain Sickness Patho
Hypoaric hypoxia
- Cerebral blood increases
- Brain enlarges
- Vasogenic Edema develops
Acute Mountain Sickness Treatment
Halt further ascent until symptoms resolve 500-1000m descent rapidly effective O2 0.5-1L/min Acetazolamide (has sulfa) ASA, tylenol, motrin Dexamethasone
Acute Mountain Sickness Prevention
Gradual Ascent
Avoid overexertion, ETOH, Respiratory depressant
Eat High CHO meal
Start Acetazolamide 24 hr before ascent (stop 2 days at altitude, resume if symptoms reoccur)
Dexamethasone
High Altitude Cerebral Edema
AMS w/ neuro symptoms
-ataxia, stupor, coma, CN 3,6 palsy
Trx: O2, descent/evacuate, dexamethasone, loop diuretics
High Altitude Pulmonary Edema (Si/sx)
Most lethal of high altitude illnesses
Si/sx: dry cough prog into productive, decr exercise performance incr recovery time, rales (incr post-ex), incr dyspnea, Coma, death
High Altitude Pulm Edema trx and background
Due to high pulm microvascular pressures development of pulm HTN
Trx: recognition, TOC: IMMEDIATE DESCENT, O2 (72 hr), Nifedipine
CHF (MC’s)
MC reason for admit in Medicare pts
MCC: LV dysfxn (Aortic Stenosis, HTN, A fib, CAD)
CHF (Si/sx)
hypoxemia, HTN, tachycardia, dyspnea, wt gain, rales
Right vs Lef sided
Left: dyspnea, fatigue, cough, PND, orthopnea
Right (Swelling)): Peripheral Edema, JVD, RUQ pain
CHF Testing
CBC (anemia) Chems (lytes, renal fxn) Cardiac Enzymes Pro-BNP (released by ventricular myocardium 2/2 stretching; >200) EKG: LV hypertrophy, dysrhythmias, STEMI CXR: low sensitive, dilated upper lobe vessels, cardiomegaly, interstitial edema, enlarged pulm artery, pleural effusions, kerley lines U/s: lung: B lines (comet tails) Echo: LV/valve fxn, tamponade, VSD
CHF Trx
Adequate O2/vent (non-invasive vs invasive)
Nitro (decr preload, bp)
Morphine sulfate (decr preload, anxioloysis)
Diuretic (furosemide = MC; 90 min, causes ventilation, diuresis)
Dobutamine (+ inotropic effect w/ mild chornotropic; in addition to Nitro)
CCB: may cause pulm edema, card shock
NSAIDS: inhibit effect of diuretics
Anti-arrhythmic’s: pro-arrhythmic effects
Pulm Embolism (PE) background
3rd lead COD hospital
MCC nonsurgical maternal death peripartum
Occurs when prox venous thrombosis breaks off and travels to lung
-MC pelvic or deep LE veins (any except intracranial)
Virchow’s triad
What is virchow’s triad
Venous stasis
Vessel wall inflammation
Hypercoagulability
PE Risk Factors
Malignancy Obesity Immobilization Surgery Trauma
CHF Age > 40 Mobility (lack) Estrogen excess Long bone fx Smoke
PE Si/sx
Dyspnea, pleuritic chest pain (50%), syncope, LE pain/swell, confusion, anxiety, hyperemia
measure tibial tuberosity, <2cm difference between calves
TRIAD: PLEURISY, SOB, HEMOPTYSIS
PE Risk (wells)
Wells score 3=suspected 3=alt dx less likely 1.5= tachycardia 1.5 = immobile, sx (4 wks) 1=hemoptysis 1=malignant
0-1 = low 2-6 = mod >6 = high
PE Risk (geneva)
Age >65 Active malignant u/l LLE pain prev DVT/PE Hemoptysis Recent sx/frx tender LE veins or u/l LE edema HR 75-94 (x2>94)
Low = 2
High >2
PE risk (PERC)
PE r/o <50 PO >94% HR < 100 o prior venous thromboembolism no recent sx/trauma 4 weeks no hemopotyis no estrogen use no u/l swelling
if all yes, risk < 2%
PE testing
CXR: normal 1/3
-hamptoms hump, westermarks, felischner sign
V/Q scan
CT scan (Test of CHOICE)
-central clots, may miss small peripheral; req iodine
Echo: limited, R ventricular dyxfxn
Venous compression u/s
Blood: ABG - widened A-a gradient (alveolus vs artery) D Dimer: fibrin degradation Pro-BPN Troponin EKG: Sinus tacky (t-wave), S1Q3T3
PE trx
Heparin, coumadin, lovenox, rivaroxaban, vena caval filter (contra to anticoag)
Thrombolytic trx (indicate/contra)
Ind: massive PE, hemo unstable, massive ileofemoral DVT, large DVT w/ vascular compromise
Contra: major bleed last 6 mos, IC/spinal sx or trauma (2 mos), sx last 10d, peri/endocarditis, uncontrolled HTN (200/110), pregnancy, suspected aneurysm
Thrombolytic trx (agents)
Streptokinase
Urokinase
Alteplase
Thrombolytic trx (mech)
Embolectomy (massive PE w/ contra to fibrinolysis or unstable after)
Catheter directed thrombolyisis (alteplase + heparin)
Asthma background
Chronic reversible inflammatory d/o
Asthma Patho triad
Airway inflammation
obstruction to airflow
bronchial hyper responsiveness
Asthma Clinical Triad
Dyspnea
Wheeze
Cough
COPD
Chronic Irreversible d/o
Bronchitis: chronic productive cough x 3 dos in 2 yrs (clinical dx)
Emphysema: destruction of bronchioles and alveoli, pathologic d/x
COPD Etiology
Tobacco use (MC) Occupational exposures Environment exposures (pollution) Alpha 1-antitrypsin deficit IVDA
COPD si/sx
cough (worse in AM) SOB wheeze tachypnea cyanosis
COPD Assessment
FEV1 (pt dependent)
can also be used to monitor therapy response
Pulse ox
CXR (abnormal only 1/3)
COPD trx
Goals: reverse obstruction, provide adequate O2, relieve inflammation
Beta Agonist
Cornerstone of COPD therapy
B1: incr rate/force cardiac, SI motility
B2: bronchodilation, vasodilator, uterine relax, tremor (small airways mostly)
Ex: albuterol
Delivery: MDI/Nebulizer (Spacer w/ MDI); intermittent vs continuous, Inhaled vs IV/SQ (longer into lungs!)
Epinepherine
Bronchodilator (not B selective)
Nebulizer, SQ, IM
No benefit over albuterol
Only give IV in code
Ipratropium Bromide
blocks cholinergic stimulation of airway smooth muscle
primarily on large central airways
give w/ beta agonists
Corticosteroids
another cornerstone of therapy
decr inflammation and up regulate B receptors
high dose not recommended
-one
Mg SUlfate
Severe exacerbations
inhibits SM action potential leading to bronchodilation
Other COPD meds
Heliox (80% helium w/ O2) for severe, not for those needing increased O2
Theophylline (no longer)
Ketamine (conscious sedation); doesn’t affect VS but opens airway
BiPAP indicate/contra
indicated: cooperative, dyspnea, tachypnea, increased work to breath, hypoxemia
Contra: emergent intubate, cardiac/resp arrest, inability to protect airway/clear secretions, decreased LOC, facial trauma/deformity, recent esophageal surgery
Bipap deliver
Facial, nasal, helmet, vent
What is BiPap
Bilevel + Airway Pressure
IPAP = inspiratory; EPAP = expiatory
IPAP - EPAP = pressure support (PEEP)
Risk factors for death in COPD
Prev severe exacerbation (intubate/ICU) >2 hospital >3 ED hosp/ED last month >2 MDIs/month Diff perecieng symptom severity low SES illicit drug use Psych illness
COPD symptom progression
Chest tightness cough wheeze prolonged expire accessory muscle use alteration in mental status
Foreign Body Aspriation
Potentially life-threatening event
peak age: 1-3; >85
4th COD accidentally @ home
RF: childhood development, too large food, fed by older siblings, small parts
Lethal objects: PB, nuts, marbles, grapes, balloons, beads, hotdog
FB aspirate adult risks
Risk: altered LOC impaired swallow Stroke dysphagia Alzheimer dementia Parkinson's
FB presentation
Depends on size and location of FB Cough (acute) stridor = laryngotracheal wheeze = bronchial SOB, cough, wheeze
universal choking sign
what if no hx?
high index suspicion
dx considered in all kids w/ u/l (esp R) wheeze + persistent symptoms that don’t respond to bronchodilators
CXR may be normal in 50%
FB Dx
CXR (radio-opaque), U/L hyper inflate
CT
Laryngoscopy/bronchoscopy
Common Locatiosn for FB
MC: thoracic inlet (~clavicles); skeletal to smooth muscle
Cricopharyngeus muscle
Mid esophagus (aortic arch/carina)
Distal esophagus (lower essophageal sphincter)
FB trx
conscious: heimlich; ask if you are choking and if i can help
Alone: self-hemilich
infant/child: between scapula on knee, CPR
Unconscious: CPR, no blind finger sweep
