Respiratory emergencies- Tx and Dx Flashcards
What organism is Bullous Myringitis caused by and how do you tx it?
Mycoplasma pneumoniae
Macrolide
What is the dx
PNA w/ lobar infiltrates
Dx?
Lobar infiltrates:
RLL PNA
Dx?
Lobar infiltrates:
PNA of the lingula of the left upper lobe
What are the 7 things you do to tx PNA
- IV fluids
- Antipyretics
- Oxygen
- Bronchodilator
- Antibiotic(s)
- Cough suppressant with expectorant
- Steroids (if COPD or recurrent PNAs)
What abx should be giving for HCAP?
- Cefepime OR Ceftazidime OR Piperacillin-tazobactam
- Ciprofloxacin OR Levofloxacin
- Vancomycin
What is the diagnostic test of choice for PNA?
CXR
How is altitude acclimatization tx?
Descent
Acetazolamide (helps correct resp alkalosis by causing bicarbonate diuresis)
How is acute mountain sickness treated? (5)
- Halt further ascent until sxs resolve (go back down)
- Oxygen (0.5-1L/min)
- Acetazolamide
- Aspirin, Tylenol, Motrin
- Dexamethasone
How can someone prevent acute mountain sickness? (5 things, 2 are meds)
- Gradual ascent
- Avoid overexertion, alcohol, respiratory depressants
- Eat high carb meals
- Acetazolamide (24hrs before ascent)
- Dexamethasone
What 4 things are used to tx high altitude cerebral edema?
- Oxygen
- Descent/Evacuation
- Dexamethasone
- Loop diuretics (Furosemide, Bumetanide)
What 4 things are important in tx of High altitude pulmonary edema?
- Recognition
- **Immediate descent is TOC**
- Oxygen (may take 72hrs to resolve)
- Nifedipine
“IRON”
What is shown here?
Cardiomegaly
What are the arrows pointing to?
**Kerley B lines= CHF
What is seen in the picture on the right and what condition is this finding characteristic of?
Kerley B lines
CHF
Is ultrasound or CXR better at diagnosing CHF?
Ultrasound (presence of B lines 94% sensitive)
What is shown in the following ultrasound report and what condition is this sensitive for?
A and B lines –> CHF
(B lines= columns: means there is fluid in lungs)
What is the tx plan for CHF?
- Adequate oxygenation and ventilation
- Nitroglycerin (reduces preload/BP)
- Morphine Sulfate (decreases preload/anxiolysis)
- Diuretic (Furosemide MC, Bumetanide can also be used)
- +/- Dobutamine (Not commonly used)
“MONDD”
What 4 things should you AVOID giving to patients w/ CHF?
- CCBs (can cause pulm edema and cardiogenic shock)
- NSAIDs (inhibit diuretics)
- Anti-arrhythmics
“CAN”
You have a pt that presents w/ pleuritic CP, SOB and hemoptysis
–> what is the most likely dx?
Triad for Pulmonary Embolism
What is the diagnostic test of choice for Pulmonary embolism?
CT
What is the name of the classic sign seen on this CXR and what condition is this indicative of?
Hampton’s Hump= Pulmonary Emboli
The following classic CXR sign is seen in what condition?
Pulmonary Embolism
What are 3 classic signs that might be seen on CXR in a pt w/ a pulmonary embolism?
- Hampton’s hump (triangular infiltrate)
- Westermark’s sign (dilated pulm vessels proximal to embolus w/ sharply demarcated cutoff)
- Fleischner sign (distended central pulm aa)
The following CT results show what condition? Which side is more severe?
Pulmonary embolism
Left= saddle PE (usually fatal)
How do you tx a pt w/ a PE?
-
Anticoagulation
- Heparin
- Coumadin
- Lovenox
- Rivaroxaban (Xeralto)
- if anticoag CI: vena caval filter
- +/- Thrombolytics for massive PE if not contraindicated (major bleed w/in 6 mo, recent surgery, suspected aneurysm, etc)
- Streptokinase
- Urokinase
- Alteplase (Activase) tPA–> only one FDA approved
- +/- embolectomy (if massive PE w/ CI to fibrinolysis)
- +/- catheter directed thrombolysis (if CI to fibrinolysis)
How would you tx a pt w/ a massive PE?
- Anticoagulation
- Heparin, Coumadin, Lovenox, Rivaroxaban
- Venal caval filter if CI to anticoag
- Thrombolytics
- Streptokinase
- Urokinase
- Alteplase (Activase) tPA--> only one FDA approved
- +/- Embolectomy if CI to fibrinolysis
- +/- Catheter directed thrombolysis if there are contraindications to the other treatments
How do you tx a massive PE with contraindications to fibrionlysis or unstable after fibrinolysis?
- Anticoagulation
- Embolectomy
What is Catheter directed thrombolysis used to tx and what meds are used?
Massive PE
- Alteplase infused over 4 hours
- Begin heparin infusion (no bolus) after alteplase completed
How do you tx asthma/COPD in the ED?
- Beta agonist- Albuterol
- via MDI or nebulizer (both have equal efficacy but prob use nebulizer in ED b/c easier)
- Ipratropium Bromide (given w/ albuterol)
-
Corticosteroids
- Dexamethazone, Methylprednisolone, Prednisone
- high dose steroids not recommended
- Magnesium sulfate (for severe exacerbations)
- Heliox (MCly used in peds but not usually recommended)
- +/- Ketamine (conscious sedation)
- +/- Epinephrine (studies show no better than albuterol)
Would you give a beta agonist continuously or intermitently in a severe asthma/COPD exacerbation seen in the ED?
continuous
What med is no longer recommended in the tx of asthma/COPD exacerbations?
Theophylline
(b/c of narrow therapeutic window and many side effects)
instead of using a beta agonist, Ipratroprium bromide and corticosteroids to tx asthma/COPD in the ED, what else can be used?
Non-invasive ventilation:
BiPAP- bilevel positive airway pressure (pt usually comes in on CPAP and is switched over to BiPAP b/c this is more physiologically normal)
(for moderate-severe dyspnea but no need for intubation)
When should FB aspiration ALWAYS be considered?
In kids w/ unilateral wheezing and persistent sxs that don’t respond to bronchodilators
What does the following CXR show?
(this is very subtle and probably won’t be on the exam)
Hyperexpansion of the R lung due to FB aspiration
Where is this FB? Why?
Esophageal FB in the Thoracic inlet =
- Thoracic inlet b/c at the level of the clavicles, site of anatomical change from skeletal to smooth mm, also transition of cricopharyngeum mm
- Esophageal b/c coin is flat, and posterior to trachea (black line on right pic)
(test question)
Where is this FB?
Esophageal FB
(b/c can see trachea/black line to the left)
Where is this FB
(this is tricky, prob won’t be question)
Esophageal FB (b/c below bifurcation of the trachea)
Thoracic inlet, mid or GE junction
Where is this FB located?
Right mainstem bronchi
What is concerning about this FB?
It is a button battery! Can cause necrosis and burn hole through structure
MUST BE REMOVED
How do you tx FB aspiration in a conscious patient?
Ask “are you choking” and “may I help you”
if pt can answer then let them cough, if can’t then perform the heimlich maneuver
How do you tx a FB aspiration in an infant/child?
place infant stomach down across your forearm and give 5 quick, forceful blows on the infants back w/ the heel of your hand
How do you tx a FB aspiration in an unconscious patient? What should you not do?
- CPR
- Magil forceps removal
(do NOT perform blind finger sweep)
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 tx?
Legionella
tx w/ Macrolide (Azithromycin)
What is the tx of choice for high altitude pulmonary edema?
Immediate descent
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. You give IV fluids, O2, monitor and obtain the following CXR.
How do you tx (in general)?
- Antibiotics
- Antipyretic
- Nebulized treatments
You are evaluating a 56 year old male with history of colon cancer, on chemotherapy, who presents w/ SOB. Vitals: 90/40, 123, 28, 87% RA, 101.1. You give IV fluids, O2 and monitor. CXR is negative. What is your next step?
Order CT
CT shows BI PE so give anticoagulation
