UWORLD Pulmonary And critical Care Flashcards
How to confirm endotracheal tube placement
Checking depth, chest excursion, and bilateral breath sounds.
If bronchial intubation due to excessive depth, retract ETT a few centimeters and recheck placement
Needle decompression vs chest tube in pneumothorax
Use Needle decompression for emergency treatment in pt with imminent cardiac arrest. Must always be followed by chest tube.
Avoid needle decompression if there is time for a chest tube (aka pt who has not developed tension physiology)
Tension Physiology
Compression of mediastinal structures and marked hypotension.
Can quickly develop from pneumothorax (specially if large)
Abdominal compartment syndrome features
Decrease perfusion to intrabdominal organs:
Renal: decreased urine output, increased CR
Lungs: High ventilation pressure
CV: venous return obstruction, decreased CO, JVD
Abdominal compartment syndrome mechanism
Massive resus + systemic inflammatory response + increased capillary preameabillity +third spacing = increased intraabdominal pressure = decreased perfusion to intraabdominal organs and thoracic compression
Next step in Management of abdominal compartment syndrome
Confirm diagnosis: measurement of bladder pressure
TX abdominal compartment syndrome
Temporarily measure: avoid over resus. Decrease abdominal volume (NG), increase abd wall compliance (sedation)
Definitive treatment: surgical decompression
Fever post PE
Acute PE can cause fever in 15% of cases. Check for other sites of infection but continue to monitor and continue treatment for PE without Abx (unless other source found)
Aerosolized racemic epi use?
Primarily indicated for laryngeal swelling in croup and angioedema
COPD exacerbation treatment
inhaled Albetro, IV steroid
ABX if 2 of the following:
Increased sputum purulence
Increased sputum volume
Increased dyspnea
Or mechanical ventilation (counts for 2)
Smoker with non resolution of pneumonia or repeat pneumonia in the same location
Suspect presence of an obstructing endobronchial neoplasm leading to a non resolving pneumonia.
CT scan can help in seeing neoplasm amidst consolidation.
If not helpful, broncoscopy
Lung mass with low sodium and symptoms. Management
SIADH due to Small cell
Hyponatrmiaa is due to water retention and loss of Na & K.
Correct slowly with water restriction if no neurological symptoms
Severe hypoNa demeclocyline or lithium
Causes of post operative hypoxia
Immediate:
Obstruction/ Edema
Residual anesthesia effect
Bronchospasm
1-5days:
Atelectasia
Pneumonia
PE
Features of obstruction/ edema caused postop hypoxia
Strider
Often due to endotracheal intubation or pharyngeal muscle laxity
Features of residual anesthesia caused postop hypoxia
Use of anesthetic agents, benzodiazepines, opiates
Diminished respiratory drive (decreased respiratory rate or tidal volume)
Hypoventilation leads to respiratory acidosis with normal A-a gradient
Correct with supplemental O2
Features of bronchospasm causes postop hypoxia
Early but not immediate
Wheezing
Features of pneumonia caused postop hypoxia
Typically 1-5 days post op
Fever elevated white blood cell count
Prurulent secretions
Infiltrate on cxr
Features of atelectasia caused postop hypoxia
Typically 2-5 days postop
Thoracoabdominal surgeries
Splinting, reduced cough, retained secretions
obstructive sleep apnea and postop hypoxemia
OSA increases risk due to sedation and neuromuscular blocker causing decreased pharyngeal muscle dilator tone and higher propensity for obstructive apneic or hypopneic events.
THis leads to severe hypoventilation and respiratory failure IMEDIATE following surgery
Cardiac death criteria for death
Irreversible electric and mechanical asystole (circulatory arrest)
Apnea is universal, requires no formal testing
Confirmed by observation period (~5min) off life support
Brain death criteria for death
Brain stem & brain stem activity cease, but heart still beating
Irreversible coma without confounding factors (e.g intoxication)
Absence of brain stem reflexes
Apnea requires formal testing to rule out residual brain stem function
Patient breathing above the ventilator set rate with severe neurological damage.
Can donate?
Apnea is NOT PRESENT! Does not meet criteria for death
Mass suspicious for lung malignancy.
Best next step in management?
Therapy and prognosis depends on histological type and accurate staging. Important to stage prior to initiating tx.
Clinical Assessment
CT scan or PET
Radionuclide bone scans
When is mediastinoscopy indicated for lung mass
scope with mediastinal lymph node sampling is indicated to document the presence or absence of malignancy in pt with suspected nodal involvement on chest CT scanning.
Lung cancer screening
annual low-dose helical CT scan
Beginning at age 50
≥20 pack-years who currently smoke or quit within the past 15 years
