SOB Flashcards
In the emergent SOB pt, while you are assessing your patient’s ABCs, you should request the following to occur simultaneously:
- Vital signs
- O2 via nasal cannula, non-rebreather mask, or bag-valve mask
- IV access
- Cardiac and pulse oximetry monitoring
- /+ EKG
May need to consider non-invasive positive pressure ventilation (NIPPV)
What are some indications for non-invasive positive pressure ventilation?
- Moderate to severe dyspnea
- Accessory muscle use
- Paradoxical abdominal movement
- Fatigue
- RR > 25 bpm
- pH < 7.35, pCO2 >45
*What are some CONTRAindications for non-invasive positive pressure ventilation?
- Respiratory arrest/absent respiratory drive
- Hemodynamic instability
- Aspiration Risk
- Airway obstruction
- Unable to tolerate mask
- Mask does not fit
- AMS
Orthopnea is typically thought of as a symptom of CHF but can also occur in these conditions.
- COPD
- Neuromuscular disorders
- Pleural/pericardial effusions
- Ascites
Rales in the setting of JVD and peripheral edema can be suspicious for __________.
CHF
List some conditions that rales can be seen in.
PNA, PE, pleural effusions, CHF
Signs of chest trauma, including crepitus, bruising, and tenderness can be suggestive of: (3)
PTX, hemothorax, pulmonary contusion.
Explain some reasons why US can be useful in SOB pts.
- Can ID pneumothorax, pleural effusion, or consolidation. - Cardiac views can identify left ventricular dysfunction, right heart strain, pericardial effusions, and tamponade.
- LE DVTs
An non-rebreather mask requires that the patient can breathe unassisted, but unlike low flow nasal cannula, the NRB offers what advantage?
Delivery of higher concentrations of oxygen.
____________________ is the leading diagnosis of patients older than 65 who are admitted to the hospital annually.
Acute decompensated CHF
- 75-80% of these pts are admitted from the ED
Describe the difference b/w systolic and diastolic heart failure.
- Systolic failure is the hearts inability to pump the blood forward in the circulatory system. It is essentially has lost the “squeeze.”
- Diastolic heart failure occurs due the fact that the muscles of the heart are unable to relax adequately (loss of elasticity) and allow the heart to fill appropriately.
In what type of heart failure is EF preserved?
Diastolic
List some causes of systolic HF.
- Ischemic Heart Disease s/p MI
- Coronary artery Disease
- Hypertension
- Fluid overload (and fluid retention)
- Cardiac Dysrhythmias
- Renal Disease
- Valvular Disease (i.e. regurgitation, chordae tendonae rupture)
List some causes of diastolic HF.
- Hypertension
- Infiltrative Cardiomyopathy
- Coronary Artery Disease
- Diabetes Mellitus
- Left ventricular hypertrophy
- Chronic heart valve stenosis
*Recall what an s3 and s4 indicate in suspected CHF pts.
An S3 on exam can be indicative of fluid overload, while a S4 heart sound is associated with diastolic heart failure with stiff, non-pliable ventricles.
List the most common sx of CHF (4).
- DOE
- Orthopnea
- PND
- Hemoptysis
List the common PE signs of CHF (8).
- Rales/wheezing
- JVD
- BLE edema
- LE venous stasis
- S3/S4
- Hepatomegaly/hepatojugular reflex
What labs and tests should you order in the CHF pt?
- EKG, cardiac enzymes (r/o cardiac ischemia)
- BMP (*r/o renal involvement, lyte disturbance)
- CBC (r/o contribution of anemia/thrombocytopenia)
- CXR
- BNP
BNP is released as a response to ___________________.
increased ventricular wall stress
Patients whose respiratory distress is secondary to HF will have elevated level of BNP greater than ____ pg/mL.
500 pg/mL
In CHF patients with moderate or severe respiratory distress, the application of _____________________ has been the only therapy used in management of HF that has consistently demonstrated decreased morbidity and mortality.
non-invasive ventilation (CPAP or BiPAP)
- Reduces need for endotracheal intubation and mechanical ventilation
In the past, what was the main tx of acute CHF exacerbation?
Diuretic monotherapy
When is diuretic therapy indicated for the CHF pt?
If there is clinical evidence of FLUID OVERLOAD with increased jugular venous distention and other clinical findings
- *It is imperative to note, that many patients presenting with heart failure are, in fact, euvolemic and will become hypotensive with diuretic therapy.
What is now the first-line tx for CHF exacerbation, and how does it work?
Focus on the use of nitrates to decrease pre-load, myocardial O2 consumption and systemic vascular resistance.
- The net result increases cardiac output and allows the heart to pump blood more efficiently through the vasculature.
Using nitroglycerin and occasionally nitroprusside (for CHF), healthcare providers must continually reassess for evidence of expected side effects including these 2 sx.
headaches and hypotension
There is a small sub-segment of the HF population who present not only with signs and sx of decompensated heart failure, but are also noted be hypotensive with cardiogenic shock. It is imperative that these patients be treated aggressively and efficiently. What medications do they require to support their BPs?
Inotropic medications including Levophed, dopamine and other peripheral vasoconstrictors (i.e. neosynephrine)
- While on these medications, vital signs and evidence of end organ perfusion must be monitored carefully.
If, despite inotropic medications for CHF pts w/decompensated HF, there is continued evidence of progressive hemodynamic collapse, what should you consider doing next? (tough question)
Mechanical circulatory support including intra-aortic balloon pumps (IABP) and ventricular assist devices (VAD) may be utilized as temporary therapy.
On average, once diagnosed CHF, most patients succumb to their illness within ___ years.
5 years
Recall the 3 categories of ACS.
unstable angina, NSTEMI, STEMI
*What’s the difference b/w stable angina and unstable angina?
- Stable angina: unchanged exertional pain lasting 5-15 minutes and relieved by rest or nitroglycerin
- Unstable angina: increasing in frequency, at lower exertional levels or occurs at rest. This is a dynamic process which may lead to MI or death.
*How is acute MI diagnosed?
Requires 2 of 3:
- A consistent clinical history
- EKG changes
- Changes in cardiac enzymes
(Later in article: “The diagnosis of ACS is ultimately made using cardiac catheterization”)
Which artery is typically affected in the following types of MIs?
- Anterior
- Septal
- Inferior
- Lateral
- Posterior
- Right ventricular
- Anterior: LAD
- Septal: LAD
- Inferior: RCA (80%) or L circumflex (20%)
- Lateral: L circumflex
- Posterior: RCA or L circumflex
- Right ventricular: RCA
For posterior MI, what ST changes would you expect?
Reciprocal ST depression in V1, V2, V3
For inferior MI, what ST changes would you expect?
Reciprocal ST depression in I, aVL
Describe what leads will show ST elevation in the following types of MIs.
- Anterior
- Septal
- Inferior
- Lateral
- Posterior
- Right ventricular
- Anterior: V1, V2, V3, V4, V5, V6
- Septal: V2, V3, V4
- Inferior: II, aVF, III
- Lateral: I, aVL, V5, V6
- Posterior: V7, V8, V9
- Right ventricular: V1, 4VR
Troponin I Following cardiac ischemia, what is the time to: - Initial elevation - Peak elevation - Return to baseline
- Initial elevation: 3-12 hrs
- Peak elevation: 10-12 hrs
- Return to baseline: 3-10 days
Troponin T Following cardiac ischemia, what is the time to: - Initial elevation - Peak elevation - Return to baseline
- Initial elevation: 3-12 hrs
- Peak elevation: 12-48 hrs
- Return to baseline: 5-14 days
CK-MB Following cardiac ischemia, what is the time to: - Initial elevation - Peak elevation - *Return to baseline
- Initial elevation: 4-12 hrs
- Peak elevation: 10-24 hrs
- *Return to baseline: 48-72 hrs
Myoglobin Following cardiac ischemia, what is the time to: - Initial elevation - Peak elevation - Return to baseline
- Initial elevation: 1-4 hrs
- Peak elevation: 6-7 hrs
- Return to baseline: 18-24 hrs
What is the most sensitive cardiac marker?
Troponin I
- Detectable in serum 3-6 hours after an MI, and its level remains elevated for 14 days.
Besides cardiac enzymes, what other tests should you consider ordering for MI w/u?
- CBC (anemia may be a cause),
- CXR (may show pulmonary edema or other causes of chest pain),
- electrolyes, BUN and creatinine (may effect treatment regimens),
- echocardiogram (usually after admission to look for regional wall motion abnormality),
- stress testing (either exercise or chemically-induced exertion to look for EKG changes and/or decreased radionuclide uptake in the ischemic region).
*For a ST-elevation MI (STEMI), what criteria is needed to actually say there is ST elevation in the lumb leads? In the precordial leads?
- Limb leads: ST-elevations of 1 mm or more in two contiguous limb leads (high lateral: I, aVL; inferior: II, III, aVF)
- Precordial leads: 2 mm elevations (anterior: V1, V2, V3; lateral: V4, V5, V6).
If you’re strongly considering dx of MI in a pt w/o quite enough troponin and EKG evidence, how do you make the diagnosis?
TIMI Risk Score for Unstable Angina and Non-ST-Elevation MI’s (UA/NSTEMI)
Describe the criteria of the TIMI Risk Score for UA/NSTEMI.
65 or older? 3+ CAD risk factors? Known CAD? Aspirin use in past week? Severe angina? ST segment changes? Positive cardiac markers?
*What is the initial tx for MI?
IV O2 monitor!
MONA greets all patients at the door.
- IV access
- Cardiac monitor
- Morphine (no longer given)
- O2
- Nitroglycerin
- Anti-thrombin therapy (e.g. heparin)
- Anti-platelet therapy (e.g. ASA)
- Beta-blockers
Besides pharmacological tx, what is the next step for STEMI and NSTEMI pts?
- Those with persistent ST-elevations will need some sort of revascularization procedure – either pharmacological (thrombolytic) or an angioplasty in the cardiac catheterization lab.
- Those without ST-elevations should get an angiogram when appropriately as determined by the interventional cardiologist.
In ACS pts, get an EKG within ___ minutes of presentation to the ED.
10 min
True or false: One set of negative enzymes and a normal EKG does not rule-out an MI.
False
True or false: Cardiac enzyme testing will be negative in patients with angina, functional testing is needed to discover any partially occluded coronary arteries.
True
The most common trigger of acute asthma is ________________.
URI
- Others: allergens, exercise, and psychosocial stress
*What are the indications for definitive airway management in acute asthma exacerbation (rapid sequence induction and intubation)?
Severe respiratory distress AND one of the following:
- β2-adrenergic agonists (albuterol) or other medical therapies do not reverse symptoms
- Significant hypoxia even with supplemental oxygen
- Too tired to continue breathing on their own
What % of asthma pts in the ED will require airway mgmt (rapid sequence induction + intubation)?
< 1%
What tx’s/interventions are required in the ED asthma pt?
- O2 (6-8L, nasal canula or non-rebreather)
- Aerosolized B2 agonist (handheld or nebulizer)
- Cardiac monitor
- Pulse ox.
In asthma exacerbation tx, the goal of oxygen therapy should be to maintain SpO2 more than ___%
92%
*In a patient with a severe acute asthma exacerbation that is not improving with aerosolized albuterol, ____________ or ____________ should be administered.
SQ or IM epinephrine (0.2 mg, q20 min, up to 3 doses) or terbutaline (0.25 mg)
For asthma exacerbation patients who do not respond initially to albuterol, or who have a moderate to severe exacerbation, PO or IV ______________ should be administered early in the presentation.
Corticosteroids
What is the time to onset of action of corticosteroids (asthma exacerbation)?
4-6 hrs
What labs are required in EVERY asthma dx?
None, truely, unless you suspect infection as source
When is abg a good lab to order in asthmatic pts?
Only required when the pt remains hypoxic after the initiation of supplemental O2
When are PFTs helpful in asthma exacerbation?
- Confirm that the patient’s symptoms are due to obstructive lung disease
- Assess the severity of the exacerbation
- Monitor the response to treatment.
In PFTs, peak expiratory flow rate is based on which of the following: sex, age, weight, height.
sex, age, height.
The first line therapy for acute asthma in the ED is _______________ in all age groups.
inhaled β2-adrenergic agonists (available as albuterol)
Besides aerosol, how else can albuterol be given? (1)
MDI
Albuterol has an onset of action of ________ and duration of action of _________.
5 min
6 hrs
What dose of albuterol is typically given in an MDI (used for mild-mod asthma exacerbation).
How often can you repeat the dose?
two 90 mcg puffs
q 4-6 hrs
In asthma exacerbation, nebulized albuterol is usually administered every ___ minutes for up to ___ doses.
20 min
3 doses
- Each dose is 0.5-1.0 mL (2.5-5 mg) of solution in 3 mL of saline.
What’s an anticholinergic asthma agent?
When are these indicated?
Ipratropium
severe asthma or Beta-blocker induced asthma
Are anticholinergic agents ever given alone in asthma exacerbations?
No
- It can be combined with albuterol in a nebulized treatment (Duoneb) or in MDI form (Combivent)
High-risk patients who benefit from steroids in asthma exacerbation are those with frequent ED visits for:
- exacerbations,
- a history of intubation,
- currently taking steroids, or
- having a prolonged exacerbation.
For corticosteroids (asthma exacerbation tx), onset of action is ______, but it may take up to ______ to exert a significant clinical effect.
4-6 hrs
24 hrs
Besides tiotroprium, epinephrine, corticosteroids, what are some agents that may also be useful in acute, severe asthma exacerbation?
- Mg2+
- Abx (if infectious cause)
- Heliox (80:20 or &0:30 He:O2 ratio)
- Intubation (if all other measures fail)
What are some of the risks of resorting to intubation in acute asthma pts?
May result in barotrauma, PTX or hypotension from decreased venous return
What asthma tx agent is not recommended in acute asthma exacerbation?
Theophylline
Is the decision to admit an asthma pt based on their severity of initial clinical presentation or their response to tx?
Response to tx
In asthma exacerbation, the goal for discharge from the ED is to obtain more than ___% predicted or personal best FEV1 or PEFR.
70%
If you d/c an asthma pt from the ED, what should you make sure they go home with?
- Action plan
- β2-adrenergic agonists and corticosteroids
*What necessitates ICU admission from the ED in asthma pts?
Any FEV1 or PEFR <25% of predicted that improves by <10% after treatment
*What typically necessitates hospital admission from the ED in asthma pts?
Pts with poor response to treatment, persistent severe sx, persistent hypoxia (< 90% SpO2) despite supplemental O2, and those with a PEFR or FEV1 <40% predicted require additional therapies and should be admitted to the hospital (still typically the ICU)
