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CEN > Respiratory Emergencies and Thoracic Trauma > Flashcards

Respiratory Emergencies and Thoracic Trauma Flashcards

1. Describe concepts related to the care of an ED patient experiencing a respiratory emergency 2. Describe various patient presentations related to respiratory emergencies 3. List interventions necessary for a patient presenting with a respiratory emergency

1
Q

define eupnea

A

normal breathing

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2
Q

define tachypnea

A

rapid rate (depth is variable)

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3
Q

define bradypnea

A

slow rate (depth is variable)

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4
Q

define hyperventilation

A

increased depth regardless of the rate

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5
Q

define dyspnea

A

subjective sensation of difficult or labored breathing

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6
Q

define orthopnea

A

sensation of dyspnea when laying down

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7
Q

define apnea

A

absence of breathing

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8
Q

define Kussmaul respirations

A

rapid and deep breathing without pauses

usually associated with acidosis

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9
Q

define Cheyne-Stokes respirations

A

rhythmic increasing and decreasing rate and depth of respirations, which includes brief periods of apnea

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10
Q

nasal flaring

A

enlargement of nostrils during inspiration

early finding in children and infants, later in adults

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11
Q

retractions

A

inward movement of muscles of chest d/t reduced pressure w/in chest cavity

intercostal, substernal, suprasternal, supraclavicular

early finding in peds, later finding in adults

mild, moderate, severe

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12
Q

tracheal tugging

A

inward movement of trachea during respiratory distress

common in pediatric population

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13
Q

diaphragmatic breathing

A

use of abdominal muscles to breathe

normal in peds, early finding in adults

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14
Q

accessory muscle use

A

use of sternocleidomatoid, pectoralis major, trapezius, internal intercostal, and abd muscles

early finding in adult, not as strongly associated with peds

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15
Q

grunting

A

noise made at end of respiration to increase end expiratory pressure to prevent alveoli from collapsing

more common in infants and small children

exhalation against closed glottis

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16
Q

wheezing

A

musical sound

narrowing of smaller lower airways

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17
Q

rhonci

A

snoring, low pitched sound

narrowing of larger airways

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18
Q

crackles

A

grating sound

inflammation of pleural surfaces

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19
Q

stridor

A

harsh grating sound

upper airway obstruction

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20
Q

ABG in respiratory acidosis

A

ph low
PaCO2 high
HCO3 normal or high w/ compensation

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21
Q

ABG in respiratory alkalosis

A

ph high
PaCO2 low
HCO3 normal or low w/ compensation

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22
Q

ABG in respiratory acidosis with metabolic compensation

A

ph low or normalizing
PaCO2 high
HCO3 high

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23
Q

ABG in metabolic acidosis

A

ph high
PaCO2 normal or low w/ compensation
HCO3 low

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24
Q

ABG in metabolic alkalosis

A

ph high
PaCO2 normal or high w/ compensation
HCO3 high

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25
Q

metabolic alkalosis with respiratory compensation

A

ph high or normalizing
PaCO2 high
HCO3 high

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26
Q

define PE

A

deep vein thrombosis or other material that dislodged and traveled to pulmonary vasculature and is obstructing pulmonary bloodflow

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27
Q

types of PEs

A

blood
fat
amniotic fluid
air

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28
Q

blood clot PE

A

migrates from other part of body, usually R side of heart, pelvis, or DVT in legs

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29
Q

fat embolism

A

24-48 hours after long bone fx

petechiae of chest and axilla

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30
Q

amniotic fluid embolism

A

shortly after delivery

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31
Q

air embolism

A

usually d/t inadvertent air injection in IV or with dive injuries

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32
Q

risk factors for PE

A 
previous DVT
surgery last 4 weeks
estrogen use
active, metastatic CA
recent travel w/ immobility
IV drug use
age
smoking
hypercoagulable state
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33
Q

define PERC

A

Pulmonary Embolism Rule-out Criteria

decrease pre-test probability to acceptable level so no further testing required

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34
Q

criteria for PERC

A 
no hormone use
<50 yo
no DVT/PE hx
no coughing blood
no LE swelling unilaterally
SpO2 > 94%
HR < 100
no surgery/trauma last 28 days

no previous DVT = negative result

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35
Q

Wells Score overview

A 
sx DVT = 3
PE likely = 3
HR > 100 = 1.5
immobilization of 3 days = 1.5
surgery last 28 days = 1.5
previous PE/DT =  1.5
hempotysis = 1
malignancy w/ tx last 6 mo or palliative = 1

score <= 4 can r/o with dimer

previous DVT = positive result

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36
Q

sx PE

A 
sudden sob
tachypnea, tachycardia
cough w/ poss. hemoptysis
diaphoresis, syncope, fever
crackles
accentuated S2
JVD, hypotension
elevated ESR, dimer
new RBBB, peaked P waves, depressed T waves
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37
Q

PE interventions

A 
supp. O2
anticoags
fibrinolytics/thrombolytics
IV fluids
vasopressors w/ hypotension
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38
Q

define acute bronchitis

A

viral inflammation of upper airways

most common cause of antibiotic misuse

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39
Q

acute bronchitis overview

A

consider influenza

can look like simple URI in first few days and is often associated w/ simple URI

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40
Q

sx acute bronchitis

A

dry, hacking, non productive cough progressing to productive cough > 5 days

exacerbated at night, w/ deep inspiration, talking, laughing

pleuritic cp

fever unlikely

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41
Q

acute bronchitis interventions

A

OTC or Rx cough meds
humidification
bronchodilators
corticosteroids

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42
Q

define bronchiolitis

A

viral infection, usually RSV, producing copious nasal secretions

clinical syndrome in children < 2 yo

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43
Q

progression of bronchiolitis

A

upper resp prodrome followed by increased resp effort

lower resp inflammation w/ wheezing/crackles

self-limiting - distress peaks 5-7 days

wheezing may last week+

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44
Q

sx bronchiolitis

A
  • URI w/ dyspnea, cough
  • poor feeding, cranky, decreased alertness
  • tachypnea, apnea in infants
  • grunting, nasal flaring, retractions, cyanosis
  • wheezing
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45
Q

bronchiolitis interventions

A

suction nares
supp. o2
bronchodilators
admission of RR > 70

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46
Q

PNA overview

A

viral slower onset, more comment in winter

bacterial rapid onset

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47
Q

most common bacteria in CAPS

A

streptococcus pneumoniae

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48
Q

most common bacteria in HCAPS

A

aerobic gram-negative

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49
Q

most common virus in viral PNA

A

RSV, influenza, parainfluenza

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50
Q

sx PNA

A 
fever
pleuritic chest pain
productive cough
tachypnea, tachycardia
decreased breath sounds
pleural friction rub
hyporesonance, increased remitus
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51
Q

risk factors for PNA

A

hx ICU admission
leukopenia
alcohol abuse
asplenia

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52
Q

interventions for PNA

A

stable, healthy can be sent home with abx, bronchodilators, oral hydration

admitted: abx, O2, IV fluids, bronchodilators, maybe CPAP, BiPAP, intubation

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53
Q

define inhalation injury

A

burns to respiratory tract from fire in confined space or smoke exposure

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54
Q

inhalation injury overview

A

consider inhaled toxin exposure 2ndary to burning objects

damage to cilia makes it difficult to clear secretions

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55
Q

sx inhalation injury

A 
hoarse voice
stridor
wheezing
facial burns, singed nasal hair
carbonaceous sputum
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56
Q

assessing inhalation injuries

A

airway

coboxyhemoglobin

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57
Q

intervening for inhalation injuries

A

O2
airway
poss. intubation

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58
Q

define asthma

A

chronic reactive airway disease with airway hyperreactivity, inflammation, and reversible airflow obstruction

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59
Q

asthma overview

A

can be life threatening

status asthmaticus is a severe, refractory asthma attack

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60
Q

common asthma triggers

A 
environmental
URI
exercise
meds
food additives, sulfites, tetrazine
menses
GERD
cold, dry air (seasonal changes)
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61
Q

sx asthma

A 
chest tightness
cough
WOB
hyperresonance to percussion
crackles
prolonged expiratory time
respiratory alkalosis (early)
respiratory acidosis (late)
exp wheeze (early), insp wheeze (late)
decreased lower breath sounds
hypoxia
pulsus paradoxus
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62
Q

assessing asthma

A

peak flow

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63
Q

define peak expiratory flow rate

A

PEFR

objective measure of airflow

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64
Q

process of measuring peak flow

A 
sit upright, legs dangling
inhale fully, seal mouthpiece
exhale fully
note measurement
repeat 3 times and record best
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65
Q

peak flow findings

A

70-90% of predicted value or personal best: use inhalers

< 70%: seek medical attention

40-60%: moderate exacerbation

< 40%: severe exacerbation

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66
Q

short-acting beta agonists in asthma

A

relax smooth muscles of bronchioles, producing bronchodilation

tachycardia is side effect

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67
Q

types of short-acting beta agonists (asthma)

A

epi, racemic epi
albuterol
salmeterol
levalbuterol

68
Q

anticholinergics in asthma

A

inhibits contraction of bronchial smooth muscle and limits mucus secretions

side effects: dry mouth, pupil dilation, increased HR, blurred vision

69
Q

types of anticholinergics (asthma)

A

ipratropium

70
Q

corticosteroids in asthma

A

anti-inflammatory and immunosuppressant effects, which:

  • reduce airway inflammation
  • inhibit mucus production
  • decrease airway swelling and hyperactivity
71
Q

types of corticosteroids (asthma)

A

inhaled:

  • dexamethasone
  • beclomethasone
  • triamcinolone

oral: prednisone
IV: methylprednisone

72
Q

magnesium sulfate in asthma

A

inhibits smooth muscle contraction

decreases release of histamine

inhibits acetylcholine release

73
Q

metered dose inhaler (MDI)

A

drug suspended in liquid propellant

use of space recommended

74
Q

spacer (asthma)

A

increase vaporization of particles and increase lung penetration while decreasing loss of med in air or mouth

85% of meds delivered compared to 15%

always with MDI

75
Q

dry powder inhaler (asthma)

A

alternative for people who cannot use MDI

76
Q

nebulizer (asthma)

A

preferred if unable to sit upright or too sick for MDIs and spacers

best delivery method

upright to allow for deep ventilation and maximal diaphragmatic movement

if HR increases > 20bpm, stop

77
Q

dc instructions for asthma

A 
avoid triggers
hypoallergenic bedding
air purifiers
wash linens q week in hot water
carpet removal
pets outside
inside with air conditioning during early morning and midday
meds as directed
stop smoking
pretreat before exercise
78
Q

define COPD

A

preventable, treatable disease characterized by progressive airflow limitation

abnormal inflammation response that is not fully recoverable

79
Q

types of COPD

A

chronic bronchitis

enphysema

80
Q

define chronic bronchitis

A

cough and sputum production for at least 3 months during 2 consecutive years

81
Q

define emphysema

A

alveoli destruction

82
Q

sx chronic bronchitis

A 
"blue bloater"
productive cough
stocky
onset 40-50 yo
normal RR
hypoxemia
increased PaO2
cyanosis
polycythemia
cor pulmonale
peripheral edema
risk for PE
enlarged HR
83
Q

sx emphysema

A 
"pink puffer"
cough uncommon
thin
onset 50-70yo
tachypnea
PaO2 normal or slightly low
PaCO2 low or normal until end
barrel chest
accessory muscles
tripod position
pursed-lip breathing
hyporesonance
lung over inflation and low diaphragm
84
Q

interventions for COPD

A 
CPAP, BiPaP
bronchodilators
high folwer
IV fluids
monitor arrhythmias
IV corticosteroids
abx prn
85
Q

dc instructions for COPD

A 
immunize
avoid exposures to URIs
small, frequent meals for max chest excursion
adequate hydrations for moist secretions
stop smoking
86
Q

types of noninvasive positive pressure ventilation

A

CPAP

BiPAP

87
Q

define CPAP

A

constant, mild airflow at single set pressure to keep airway open

requires tight fitting mask

88
Q

define BiPAP

A

time-cycle airflow w/ two levels of pressure

lower pressure inhaling
higher pressure exhaling

requires tight fitting mask

89
Q

CPAP/BiPAP inclusion criteria

A 
hemodynamically stable
normal mental state
spontaneously breathing
tolerate mask, sit upright
handle secretions
sx resp distress
90
Q

advantages of CPAP/BiPAP

A
  • improves pulm fxn and gas exchange
  • decreases inspiratory threshold pressure
  • decreases venous return to heart
  • limits workload
  • increases functional residual capacity
  • may affect CO
91
Q

risks of CPAP/BiPAP

A

decrease venous return to heart which could decrease CO in dehydrated patient

barotrauma

aspiration if vomiting

92
Q

define pulmonary edema

A

accumulation of fluid in extravascular spaces of lungs

93
Q

types of pulmonary edema

A

cardiogenic: high pulmonary capillary pressure
noncardiogenic: pulmonary capillary permeability

94
Q

common causes of pulmonary edema

A 
ARDS
renal failure (fluid overload)
submersion injury
head trauma, szs
rapid re-expansion of lung (scuba)
high altitude
toxic gas inhalation
OD
95
Q

sx pulmonary edema

A 
sob
tachypnea, tachycardia
anxiety, agitation
sensation of suffocation
cough, crackles, wheeze
diaphoresis
pink, frothy sputum
96
Q

pulmonary edema interventons

A 
high-flow
IV, careful fluids
CPAP/BiPAP
intubation w/ low tidal volumes
supportive treatment
97
Q

define ARDS

A

form of noncardiogenic pulmonary edema

inflammatory syndrome characterized by diffuse alveolar injury in which increased permeability of alveolar=capillary barrier allows protein-rich fluid to pass into alveoli, resulting in severe hypoxemia.

98
Q

ARDS overview

A

refractory to high concentrations of oxygen associated with loss of surfactant, alveolar collapse, and decreased lung compliance

99
Q

direct causes of ARDS

A 
aspiration of gastric contents
PNA
toxic inhalation
pulm contusion
submersion injury
100
Q

indirect causes of ARDS

A 
sepsis
multiple trauma
massive transfusion
severe pancreatitis
OD
burns
DIC
shock
101
Q

sx ARDS

A 
dyspnea, tachypnea, cysnosis
tachycardia
anxiety, restless, agitated
accessory muscle use
fever or hypothermia
102
Q

how to assess ARDS

A

CXR

bronchoscopy with lavage

103
Q

interventions for ARDS

A

intubate, PEEP
low tidal volumes
careful fluids
ICU

104
Q

complications of ARDS

A

acute renal failure
hypo/er glycemia
MODS
VAP

105
Q

define pleural effusion

A

abnormal collection of fluid in pleural space

not a disease

106
Q

causes of pleural effusion

A 
HF
nephrotic syndrome
malnutrition
PNA
infected wound
lung abscess
tumor
fibrosis
trauma
infection
107
Q

sx pleural effusion

A 
dyspnea
cough
CP
dullness to percussion
decreased breath sounds
pleural friction rub
decreased chest expansion on affected side
108
Q

pleural effusion interventions

A

needle thoracentesis or chest tube if large and compromising respirations

109
Q

define airway obstruction

A

blockage in airway

110
Q

airway obstruction in larynx

A

large obstructions: complete obstruction with lack of coughing, airway sounds or airway movement

smaller obstructions: hoarseness and aphonia

111
Q

airway obstruction in trachea

A

large obstruction: complete airway obstruction with lack of coughing, airway sounds, airway movement

smaller obstructions: wheezing similar to asthma

112
Q

airway obstruction in bronchi

A

cough, unilateral wheeze, unilateral breath sound decrease

80-90% aspirated objects are in bronchi

adults: usually R bronchus
peds: R or L equally

113
Q

airway obstruction interventions

A 
heimlich
CPR
direct visualization
largyncoscope with Magill forceps
endoscope for partial/bronchial
114
Q

define spontaneous pneumothorax and simple pneumothorax

A

accumulation of air in pleural space causing partial or complete collapse of lung as air accumulates with increasing pressure

115
Q

define open pneumothorax

A

penetrating wound allowing air to enter thorax and loss of normal negative intrathoracic pressure

116
Q

causes of spontaneous pneumothorax

A

no trauma

young, thin, tall males or in smokers with pulm disease

117
Q

causes of simple pneumothorax

A

blunt trauma

118
Q

causes of open pneumothorax

A

penetrating trauma

119
Q

sx spontaneous pneumothorax

A 
sudden pleuritic CP
dyspnea, tachypnea
cough
decreased BS
hyperresonance
120
Q

sx simple pneumothorax

A 
CP
dyspnea, tachypnea
cough
decreased BS
hyperresonance
121
Q

sx open pneumothorax

A 
visible chest wound
resp distress
sucking sound
asymmetrical chest expansion
bubbling of blood around wound
subcutaneous emphysema
122
Q

intervene for spontaneous pneumothorax

A

high Fowler
monitor, pain control
chest tube at 5 or 6th ICS mid axillary

123
Q

intervene for simple pneumothorax

A

high Fowler
monitor, pain control
oxygen if small enough
chest tube if larger

124
Q

intervene for open pneumothorax

A

ABCs
3 sided occlusive dressing
chest tube

125
Q

define tension pneumothorax

A

air enters pleural space during inspiration and can’t escape during exhalation

126
Q

complications of tension pneumothorax

A

life threatening

pressure shifts mediastinum and collapses opposite lung, decreasing cardiac output

127
Q

define hemothorax

A

accumulation of blood in pleural space, usually accompanied by pneumothorax

128
Q

complications of hemothorax

A

massive hemothorax can accumulate more than 1500 ml blood in chest cavity

129
Q

causes of tension pneumothorax

A

blunt, penetrating trauma

mechanical ventilation

130
Q

causes of hemothorax

A

blunt, penetrating trauma

131
Q

sx tension pneumothorax

A 
severe resp distress
decreased CO
hyperresonance
distant heart sounds
JVD, deviated trachea
132
Q

sx hemothorax

A 
resp distress
pain on inspiration
asymmetric chest wall movement
hypovolemic shock
decreased breath sounds
dull percussion
133
Q

intervene for tension pneumothorax

A

needle decompression

immediate chest tube

134
Q

intervene for hemothorax

A

ABCs, fluids, blood
chest tube
emergent surgery with large accumulations

135
Q

breath sounds in fluid and air accumulation

A

fluid: decreased
air: decreased

136
Q

fremitus in fluid and air accumulation

A

fluid: absent
air: decreased

137
Q

lung percussion in fluid and air accumulation

A

fluid: hyperesonance
air: hyperresonance

138
Q

pain in fluid and air accumulation in lungs

A

fluid: dull ache on affected side
air: sharp pain, maybe radiating to shoulder on affected side

139
Q

egophany in fluid and air accumulation in lungs

A

fluid: near top of fluid line
air: not present over air

140
Q

fractures of 1st, 2nd ribs associated with

A 
injury to:
lungs
aortic arch
vertebra column
suclavian artery, vein

rare - needs significant force

141
Q

lower rib fractures associated with

A

splenic injury (L) hepatic injury (R)

142
Q

pediatric considerations with rib fractures

A

carilaginous ribs not easily fractured but may have significant trauma

consider abuse

143
Q

geriatric considerations with rib fractures

A

lack pulmonary reserves to compensate for rib fractures

144
Q

complications of rib fractures

A

diaphragmatic tears, liver or splenic injuries and associated bleeding with low rib fractures

cardiac or vascular damage from sternal fractures

145
Q

intervene for rib fractures

A

monitor resp status
restrict activity
pain
admission for geriatrics

146
Q

define flail chest

A

2 or more adjacent fractured ribs in 2 or more locations

or detachment of sternum

147
Q

overview of flail chest

A

life threatening

impaired ventilation caused by loss of bellows effect (less negative intrapleural pressure to expand lungs) and associated with pulm contusion dead space and atelectasis

148
Q

sx flail chest

A 
paradoxical chest movement
cp
resp distress
hemo/pneumothorax
subcutaneous emphysema
bony crepitus
increased resp effort
decreased tidal volume
impaired cough
hypoxia
149
Q

intervene for flail chest

A

mechanical ventilation with PEEP

chest tube if hemo/pneumothorax

correct hypovolemia

surgery

150
Q

define pulmonary contusion

A

injury of lung resulting in edema and blood collection in lung parenchyma

151
Q

causes of pulmonary contusion

A

severe blunt trauma
high-velocity missile trauma
significant barotrauma

152
Q

sx pulmonary contusion

A 
resp distress
chest pain
chest wall bruising
cough, hemoptysis
decreased breath sounds
crackles, wheezes
other chest injuries
153
Q

intervene for pulmonary contusion

A

high flow
intubation or CPAP/BiPAP
careful fluids
pain

154
Q

define ruptured diaphragm

A

abdominal contents herniate into chest and compress lungs, heart, aorta, vena cava

155
Q

causes of ruptured diaphragm

A

penetrating or blunt trauma

156
Q

where do most ruptured diaphragms occur?

A

L because liver protects R side

157
Q

sx ruptured diaphragm

A

dyspnea, orthopnea
dysphagia
bs in chest
abd pain radiate to L shoulder (kehr sign)
decreased breath sounds
undigested food/fecal matter in chest tube

158
Q

assessing ruptured diaphragm

A 
FAST exam
CXR will show:
-elevated L diaphragm
-herniation of bowel into chest
-NG or OG tube coiled in chest
159
Q

intervene for ruptured diaphragm

A

ABC
NG/OG tube
emergent surgical repair

160
Q

causes of concern for chest drainage systems

A

initial output >1500 ml

continued output >200 ml/hr

161
Q

bubbling or absent fluctuations in chest drainage system

A

lung re-expanded or obstruction in system

162
Q

vigorous, continuous bubbling in chest drainage system

A

large air leak on patient or drainage system

163
Q

disconnection of chest drainage system

A

clamp, clean, reconnect

assess, provider

164
Q

accidental removal of chest drainage system

A

pressure dressing, occlusive

assess, provider

165
Q

considerations for auto transfusion

A

significant blood loss

blood < 4-6 hrs

166
Q

advantages of auto transfusion

A

readily available
no risk of rxn
fresh, warm, whole blood

167
Q

contraindications for auto transfusion

A

risk of enteric contamination
ruptured diaphragm
lower chest injury
penetrating trauma

CEN (12 decks)

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