respiratory emergency Flashcards
first line imaging for hemoptysis
CXR. will follow up with CT if needed
RF for PE
injuries to the vascular epithelium (CAD, AMI, etc), Venous stasis (Vfib, Pregnancy, Obesity, varicose veins), State of coagulopathy (pregnancy, OCP, neoplasm), previous PE
there is no classic picture of PE, but have a high suspicion if see any sign
RR > 16, Chest pain, Dyspnea, Apprehension, Rales, Cough, Pulse >110, fever, Sweating, gallop, phlebitis, hemoptysis
Wells prediction criteria for PE
takes into account of you have had previous PE or DVT, if HR > 110, if recent surgery or immobilization in past month, if clinical sings of DVT, if any alternative diagnosis is unlikely, if hemoptysis and if cancer was treated in the last 6 mos
Homan sign
dorsiflex and squeeze the calf. If pain is + sign for DVT.. Document it for completeness but really it doesn’t mean anything
ABG results in PE
will show hypoxemia
D-Dimer results in PE
Will be positive. If it is negative, can r/o PE. If positive, it is not definitively PE, could be something else
Classic ECG findings in PE
S1, Q3, T3 pattern in up to 20% of cases. Large S wave in lead I, large Q wave in lead III, and inverted T wave in lead III. Remember, a normal ECG does not r/o PE
Most common ECG finding in PE
transient, non-specific ST changes
Pt comes in with severe dyspnea. CXR is normal.
PE should be on the top of differential
CXR findings in PE
elevation of one diaphragm, Hampton hump (transient wedge shaped infiltrates), Pleural effusions and atelectasis
Gold standard for PE diagnosis
pulmonary angiography “angiogram”. This is not the test of choice though- which is D-dimer and CT-angio because pulmonary angio is very invasive.
Chest CT angio findings in PE
saddle embolus
Pt with PE who is hypotensive, has sever tachycardia, hypo perfusion, or low SpO2
this pt is unstable. To tx, consider placing a central catheter and giving Fibrinolytic therapy via the catheter. This has a high mortality rate. Can also consider surgical pulmonary embolectomy
Tx for PE
LMWH (Lovenox) 1 mg/kg q 12 hrs SQ and then begin Warfarin 72 hrs after lovenox.
Indications for Greenfield IVC filter
if heparin/LMWH are c/i or ineffective
the primary factors contributing to asthma morbidity and mortality
under-diagnosis and inappropriate treatment
When to consider getting an ABG in an asthmatic exacerbation
SpO2
Asthmatic exacerbation comes to ED what do you do?
First check the airway and assess breathing. Intubate if in respiratory arrest. If not in arrest, give O2, check pulse ox and give albuterol nebulizer. can give up to 3 bolus doses in 1 hour or can give continuously if severe. Consider starting PO corticosteroids. If severe exacerbation can add ipatropium nebulizer to albuterol.
Other medication treatment options for asthma
can give Magnesium sulfate to help avoid intubation and can also give ketamine in refractory disease
anaphylactic asthma treatment
epinephrine, 0.5 mg SC or IM. Can also use if have been trying albuterol tx for over an hour with little response in a non- anaphylactic attack
respiratory failure
arterial PaO2
Respiratory acidosis
PCO2 > 44 mmHg and acidotic
serum changes in acute respiratory acidosis
for every 10 mmHg increase in Co2, there is a 1mEq increase in bicarb.
serum changes in chronic respiratory acidosis
for every 10 mmHg increase in CO2 there is a 3.5 mEq increase in bicarb
ER management of COPD exacerbation
if SpO2
When to admit your COPD exacerbation patient
if they cannot ambulate without their O2 dropping below baseline, they get admit.d If they have significant co-morbidities, newly occurring cardiac issues, or if they are on a ventilator, they get admitted. If their pulse ox is 92% or below you should consider observation overnight.
Type 1 ARF
ABG shows hypoxemia PaO2
Type 2 ARF
ABG shows hypercapnic PaCO2 > 50
asterixis is a sign of
hypercapnia. ASterixis is flapping tremor of hand
Indications for intubation
Persistant Hypoxemia, Progressive acidemia, Progressive hypercapnea, AMS, evidence of respiratory muscle fatigue
ARF management in the ER
stabilize the airway and breathing and circulation. Put them on O2, get ABGs, intubate if necessary and send them off to ICU
a major indication of ARDS
pulmonary cap wedge pressure
the most common cause of ARDs
pneumonia (direct lung injury) That is followed p by sepsis (indirect lung injury)
rosk factors for ARDS
pre-existing lung disease, chronic EtOHism, Sepsis
top of the Ddx list for ARDs
pulmonary edema from Left HF
medications that do not help with ARDs
steroids, ketoconazonle, inhaled NO, surfactant
Most frequent sx in the ED of pneumonia
Fatigue, Cough, Fever
The two best things to order in the ED if suspect pneumonia
CXR and SpO2
Pt presents with sudden onset cough, fever and rigors, has rust colored sputum and CXR shows lobar infiltrates with occasional patches and effusions. What is the most likely organism?
Streptococcus pneumoniae
Pt presents with gradual onset cough and fever, has purulent sputum and CXR shows patchy, multi lobar infiltrates. What is the most likely organism?
Staph aureus. Can also cause empyema and abscess.
Pt presents with sudden onset rigors, dyspnea, and bloody sputum. CXR shows upper lobe infiltrate with a bulging fissure sign. What is the most likely organism?
Klebsiella. May also have currant jelly sputum
Pt presents after recently being hospitalized, and has fever and cough. CXR shows patchy infiltrates. What is the most likely organism?
P. Aeruginosa
Pt presents with gradual onset fever and pleuritic chest pain. CXR sows patchy basilar infiltrate. What is the most likely organism?
H. Influenzae. more common i elderly and COPD pts
pt presents with fever, chills, HA, dry cough and vomiting. CXR shows multiple patchy infiltrates with occasional civilization. What is the most likely organism?
Legionalla pneumonia
Pt presents with long course of a cough, fever, chest pain and sputum that shows gr- diplococci. CXR shows diffuse infiltrates. What is the most likely organism?
M. catarrhalis
Pt present with gradual onset fever, dry cough, wheezing and sinus sx. CXR shows patchy sub-segmental infiltrates. What is the most likely organism?
Chlamydophilia pneumoniae
Pt presents with upper and lower respiratory tract sx, nonproductive cough, HA and fever. CXR shows interstitial infiltrates. What is the most likely organism
Mycoplasma pneumona
Pt presents with gradual onset of putrid smelling sputum. What is the most likely organism?
an anaerobic collection of organisms.
First line treatment for uncomplicated pneumonia
Z-pack or clariththromycin x7d.
Pt presents with pleuritic chest pain, dyspnea and cough. What is their most likely diagnosis?
pleural effusion.
Pleural effusion CXR findings
air-fluid lines, blunting of the costophrenic angle, meniscus sign
Transudate PE
there is no local pleural disease, rather the fluid in the lungs is do to some other cause that is causing pooling of fluid into lungs, like CHF, acute atelectasis, hypoalbuminemia, etc
Excudate PE
there is altered permeability of the pleural membranes, increased capillary permeability or backup from the lymphatics
Pleural fluid is excudate if
ratio of pleural fluid: serum protein > 0.5, if ratio of pleural fluid: serum LDH > 0.6
Normal pleural fluid
pH 7.6, clear, protein
Primary spontaneous PTX
there is no underlying lung disease. Think tall, thin, young males
secondary spontaneous PTX
there is underlying lung disease like COPD
tension PTX
defined as having POSITIVE PRESSURE in the pleural space
Immediate management of PTX
give oxygen, aspiration and Chest tube if aspiration doesn’t work
needle aspiration/decompensation
use 14/16 g needle, go 2nd ICS MCL, above the 3rd rib space.
Chest tube placement for PTX
4th ICS anterior axillary line, point up
Chest tube placement for HTX
4th ICS, mid axillary line
pt presents with absent breath sounds, distended neck veins and Hypotension. What is it?
could be a tension PTX, EMERGENCY
Pt presents with absent breath sounds, hypovolemia and dullness to percussion over lung fields. What is it?
HTX!
