Penney 4-11-08 Pulmonary Emergency

Front 1

Why is epiglottitis MC in adults

Back 1

Hib vaccine

Front 2

Clinical findings of epiglottitis

Back 2

severe sore throat& minimal findings
May see drooling, head held in slight flexion
May elicit pain when moving thyroid cartilage
Lateral neck x-ray – swollen epiglottis that appears “thumb” shaped

Front 3

IN ER setting, what do you do for epiglottitis pt?

Back 3

get ready: Surgical airway tray & intubation tray at bedside
Stat ENT & Anesthesia consult
Direct laryngoscope in the OR by ENT & anesthesia for possible intubation or tracheostomy
Treat for H. Influenza

Front 4

Complications of pertussis

Back 4

from cough (Hernia, rectal prolapse ruptured diaphragm)
- Neurologic Sequelae from hypoxia & Cerebral hemorrhages—encephalopathy, seizures
- Secondary bacterial infections
Death secondary to bacterial pneumonia

Front 5

Treatment: of pertussis

Back 5

erythromycin, bactrim
Chemoprophylaxis for all exposed

Front 6

Preciptants of Asthma/ Reactive airway disease

Back 6

Precipitants: URI
Allergic
Respiratory irritants
Cold
Exercise
GERD
Beta-blockers
Cholinergic stimuli

Front 7

Cliniacal Effects of Asthma/ Reactive airway disease

Back 7

Clinical Effects: 1. Increase airway resistance
2. Decrease flow rate
3. Air trapping
4. Hypercarbia, hypoxemia
5. Pulsus paradoxus(decrease in BP >10 with
inspiration
6. Muscle fatigue/respiratory failure

Front 8

Pulse oximetry's role in Asthma outcome

Back 8

none

Front 9

Severe Asthma signs

Back 9

Severe Asthma:
Absence of wheezing* (bad sign - not moving enough air to wheeze)
Inability to speak
Pulsus paradoxus >20
Normal to elevated CO2
Hypoxemia
PEFR <50% of predicted or pt’s baseline<80L/min
CHF, FB, obstruction, infection – ALL may wheeze

Front 10

Before PEFR, ER docs used to used FEV1/FVC. What should the normal value be?

Back 10

0.75

Front 11

If the difference between inspiratory and expiratory SBP is >__ mm Hg, the PP is abnormally high

Back 11

If the difference between inspiratory and expiratory SBP is >12 mm Hg, the PP is abnormally high

Front 12

Tamponade produces PP of __-__ mm Hg

Back 12

Tamponade produces PP of 20-30 mm Hg

Front 13

Risk Factors for Increased Mortality from asthma

Back 13

Past Hx of sudden severe attacks
2 or more hospitalizations in past 12 months
Prior intubation or ICU admission
3 or more ED visits in 12 months
Asthma emergency within past month
Use of 2 or more adrenergic canisters per month
Current use of systemic steroids or recent withdrawal
Co morbidities
Illicit drug use
Low socioeconomic class

Front 14

Major cause of bronchitis?

Back 14

Majority are viral

Front 15

Bacterial causes of bronchitis

Back 15

Pertussis, mycoplasma, chlymadia, strep

Front 16

Sputum color of brochitis

Back 16

Sputum may be clear or colored (color does not indicate bacterial vs. viral)

Front 17

Dx of bronchitis

Back 17

cough for 1 week, no lung disease, normal O2 saturation and normal lung exam

Front 18

Tx of bronchitis

Back 18

Nine RCT reveal that there is NO benefit to antibiotic therapy (unless underlying COPD)
Bronchoodilators may be of benefit (consider steroids?)

Front 19

Chronic Bronchitis – excess mucous secretion in the bronchial tree with chronic productive cough occurring on most days for at least _ months in the year for _ consecutive years

Back 19

Chronic Bronchitis – excess mucous secretion in the bronchial tree with chronic productive cough occurring on most days for at least 3 months in the year for 2 consecutive years

Front 20

Pulses paradoxus above __ mm Hg indicates severe air trapping leading to auto-PEEP

Back 20

Pulses paradoxus above 20 mm Hg indicates severe air trapping leading to auto-PEEP

Front 21

Signs of hypercapnea include:

Back 21

confusion, tremor, plethora, stupor, hypopnea and apnea

Front 22

High risk for respiratory failure with COPD include

Back 22

attacks lasting for several days, dependence on steroids, prior attacks requiring intubation

Front 23

CXR_ of COPD may show...

Back 23

hyperaeration(increase AP diameter, flattened diaphragms, parenchymal lucency, attenuation of arterial vascular shadows

Front 24

EKG in mod to severe COPD

Back 24

EKG: in moderate to severe pulmonary disease
- Right ventricular strain
- Abnormal p waves
- NSST (non-specific ST-T changes)
- MAT (multifocal atrial tachycardia)

Front 25

Acute treatment of COPD

Back 25

Acute Treatment
- O2 with caution, maintain O2 saturation >90
- bronchodilators (same as asthma)
- Antibiotics recommended
- Steroids for severe cases
- Mechanical ventilation for respiratory muscle fatigue, hypoxia refractory to treatment, worsening respiratory acidosis)
- Avoid sedatives

Front 26

Venous thromboembolic disease represent a continuum of disease from deep venous thrombosis(DVT) to __________ _________(___)

Back 26

Venous thromboembolic disease represent a continuum of disease from deep venous thrombosis(DVT) to pulmonary embolus(PE)

Front 27

Tx of PE

Back 27

unfractionated or low molecular weight heparin

Front 28

Dx of PE

Back 28

History and PE findings for PE or DVT are neither sensitive nor specific

Front 29

Risk factors for PE

Back 29

Stasis – immobilization, obesity,venous insufficiency,CHF
Endothelial Damage: trauma,Post-op, tobacco
Hypercoagulable: Cancer, clotting abnormality, pregnancy, tobacco, oral contraceptives

Front 30

How long after pregnancy is pt hypercoaguable?

Back 30

30 days

Front 31

Symptoms of PE

Back 31

- Dyspnea(80-90%)
- Pleuritic Chest Pain (80-90%)
- Cough (50%)
- Shock (10-35%)
- Syncope (10-35%)

Front 32

Signs of PE

Back 32

- Tachycardia (80-90%)
- Tachypnea (80-90%)
- Fever (50%)
- DVT (50%)
- Wheezing
- Rales

Front 33

Pulmonary Embolism Risk Factors (long list)

Back 33

Prior history PE or DVT
Recent pregnancy or surgery
Prolonged immobilization
Malignancy especially peritoneal
Hypercoaguable state
Deficiency antithrombin III, protein C or S
Presence circulating lupus anticoagulant
Use of oral contraceptives
Obesity(>120% ideal body weight)
Presence central line
Orthopedic trauma especially long bones, pelvis
Polycythemia and thrombocytosis

Front 34

ABG in PE

Back 34

ABG: hypoxemia with increase A-a gradient(>20 mm Hg)
<10% have normal A-a gradient

Front 35

EKG in PE

Back 35

EKG: NSTT changes and or sinus tachycardia are the most common EKG findings
- sign of right heart strain(new RBBB, tall R in aVR)
- S1Q3T3
- right axis deviation
- p-pulmonale (peaked P wave in lead II)

Front 36

CXR of PE

Back 36

CXR:
- cardiomegaly most common finding
- elevated hemidiaphragm most common
- atelectasis, infiltrates, pleural effusion
-* Hampton’s hump – pleural based wedge shape density
-* Westermark’s sign – dilated pulmonary vasculature proximal to embolus and oligemia distally
- Hypoxemia with apparently normal CXR should raise your suspicion

Front 37

V/Q scan of PE?

Back 37

V/Q Scan:
- normal virtually rules out PE
- low, medium, indeterminate, need to interpret in light of clinical suspicion, may require further testing (doppler, CTPA)
- high probability has >80% chance of PE

Front 38

Doppler of PE?

Back 38

Doppler
- most >90% of PE arise from legs
- less invasive
- more sensitive for thigh DVT

Front 39

D-Dimer of PE?

Back 39

D-Dimer (ELISA)(Normally elevated in thromboembolic disease)
- highly sensitive but not specific
- high negative predictive value
- may be useful to exclude PE if low clinical suspicion

Front 40

CTPA of PE?

Back 40

CTPA
- accurate for proximal PE
- may miss small peripheral PE
- may identify other diagnosis

Front 41

Tx for PE?

Back 41

Oxygen
Hemodynamic support
Heparin or LMWH
Long term warfarin
Thrombolytics for massive PE/hemodynamic compromise
IVC filter (if large PE or contraindication to anticoagulation)
Embolectomy rarely done

Front 42

2 types of pleural effusions

Back 42

Transudative
Exudative

Front 43

cause of transudative

Back 43

caused by increased hydrostatic pressure or decreased intravascular oncotic pressure
- CHF more common on right
- Cirrhosis
- Nephrotic syndrome

Front 44

Causes of exudative

Back 44

- Neoplastic
- Inflammatory (SLE, pancreatitis, Rheumatoid arthritis)
- Infectious (pneumonia, empyema, abscess, TB)

Front 45

the most common cause of pleural effusions in western countries is___, followed by malignancy, bacterial pneumonia, pulmonary embolism

Back 45

the most common cause of pleural effusions in western countries is CHF, followed by malignancy, bacterial pneumonia, pulmonary embolism

Front 46

in developing countries __ remains leading cause of pleural effusions

Back 46

in developing countries TB remains leading cause of pleural effusions

Front 47

Can you clear a c-spine with a n x-ray

Back 47

no

must be cleared clinically with Nexus criteria

Front 48

3 questions when assessing airway

Back 48

Is the patient breathing?
Is there obstruction?
Is the airway at risk?

Front 49

Before you touch the patient insure that the _______ is immobilized!

Back 49

Before you touch the patient insure that the C-spine is immobilized!

Front 50

Indications for Surgical Airway

Back 50

Failure to intubate
Apneic with suspected C-spine injury
Facial trauma with suspected C-spine injury
Severe facial + Neck trauma = altered anatomy

Front 51

State in which spontaneous respirations are inadequate for sustenance of life

Back 51

Acute Respiratory Failure

Front 52

Respiratory rate of acute respiratory failure

Back 52

RR >30 breaths/min or <6/min

Front 53

Normal A-a gradient =

Back 53

Normal A-a gradient = 10 mm Hg + (0.3 X patients age)

Normal = Age/4 + 4

Front 54

Formal calculation of A-a

Back 54

713(FI02) – PaCO2/.8 – PaO2

Front 55

A-a formula that is easy and should be memorized

Back 55

150 –(paO2 + PCO2/.8)

Front 56

Generally ARF is imminent when PO2 <__ mmHG or PCO2 >__mm HG

Back 56

Generally ARF is imminent when PO2 <60 mmHG or PCO2 >45mm HG

Front 57

For resp failure:
CXR: can generate differential diagnosis by classifying the radiograph as black or white

Back 57

Black: radiolucent film
- normal film
- pulmonary embolism
- asthma
- COPD
- pneumothorax
White: radiopaque film
- bacterial pneumonia
- aspiration pneumonia
- pulmonary edema / contusion
- pleural effusion

Front 58

Tx of Resp failure

Back 58

Treatment: 2 fold
Manage the airway with intubation and mechanical ventilation + supplemental oxygen
Indications for intubation
Treat underlying cause of acute respiratory failure

Front 59

Criteria for Intubation

Back 59

Whenever the patient cannot maintain adequate ventilation on their own
When they cannot protect their airway from secretions & foreign matter
Intubate when there is risk to the airway such as an airway burn
Intubate if the patient likely will have ongoing respiratory distress i.e.. COPD with pulmonary contusion
Intubate if the patient has a head injury with a GCS <8

Front 60

Examples of Inadequate Respirations

Back 60

Cardiac Arrest
Respiratory Arrest (i.e.. Narcotic overdose)
Respiratory failure (i.e.. Status asthmaticus)
Severe lung disease (i.e.. Pulmonary contusion)
Traumatic Respiratory Distress
Neurologic Injury(CVA, Herniation, Post. Fossa lesion)

Front 61

Examples of Protection

Back 61

Prolonged unconsciousness
Inadequate gag reflex (i.e.. Drug overdose)
Airway encroachment (burn/bleeding)
Status epilepticus
Transfer of patients from institution to institution – concern of stability of airway en route

Front 62

Difficult ventilation:

Back 62

inability of a trained anesthetist to maintain the oxygen saturation >90% using a face mask for ventilation & 100% inspired oxygen, provided that the pre-ventilation oxygen saturation level was within the normal range

the need for more than three intubation attempts or attempts at intubation that last >10 min

clinical factors that complicate either ventilation administered by face mask or intubation performed by experienced and skilled clinicians

Front 63

TIming of adverse intubation sequellae in oxygenated vs .non oxygenated pts.

Back 63

oxy - 10 mins tolerated
non-ox - less

Front 64

complications occur in up to __% of patients requiring emergent intubation

Back 64

complications occur in up to 78% of patients requiring emergent intubation

Front 65

Incidence of esophageal intubation & aspiration ranges from 8 to __%, and 4-__% respectively

Back 65

Incidence of esophageal intubation & aspiration ranges from 8 to 18%, and 4-15% respectively

Front 66

Mallampatic class is devised by having patients sit up, open their mouth, and pose in the “________ position”(i.e.. Neck flexed with atlantoaxial extension) with the tongue voluntarily protruded maximally while the physician observes posterior pharyngeal structures

Back 66

Mallampatic class is devised by having patients sit up, open their mouth, and pose in the “sniffing position”(i.e.. Neck flexed with atlantoaxial extension) with the tongue voluntarily protruded maximally while the physician observes posterior pharyngeal structures

Front 67

Mallampati classes
ranks tongue size relative to mouth size
based on Faucial Pillars
Soft Palate
Uvula

Back 67

I: uvula fully visualized
II: uvula view partially obstructed
III: top of uvula visible
IV: uvula view obstructed

Front 68

Factors Predicting Difficult Intubation

Back 68

Mouth opening <7cm (three fingertips)
A cervical range of motion of <35 degrees of atlanto-occipital extension
A thyromental distance of <7cm (three fingerbreadths)
Large incisor length
A short, thick neck
Poor mandibular translation
Narrow palate(three finger breadths)
In the ED nearly 70% of patients undergoing RSI have either altered mental status or cervical spine collars in place that prevent the assessment of these predictive factors

Front 69

the 9 P's of Rapid sequence intubation

Back 69

seeslide 70

Front 70

Critically ill patients who require emergent intubation experience hypoxia, hypercarbia, & acidosis, which induce an extreme sympathetic outflow that is associated with tachycardia, labile BP, and increased myocardial contractility, and/or vasodilation, which result in postintubation hypotension

Back 70

Critically ill patients who require emergent intubation experience hypoxia, hypercarbia, & acidosis, which induce an extreme sympathetic outflow that is associated with tachycardia, labile BP, and increased myocardial contractility, and/or vasodilation, which result in postintubation hypotension

Front 71

ETT can provoke bronchospasm & coughing aggravating asthma, intraocular hypertension, and ICP

Back 71

ETT can provoke bronchospasm & coughing aggravating asthma, intraocular hypertension, and ICP

Front 72

For resp failure:
CXR: can generate differential diagnosis by classifying the radiograph as black or white

Back 72

Black: radiolucent film
- normal film
- pulmonary embolism
- asthma
- COPD
- pneumothorax
White: radiopaque film
- bacterial pneumonia
- aspiration pneumonia
- pulmonary edema / contusion
- pleural effusion

Front 73

Tx of Resp failure

Back 73

Treatment: 2 fold
Manage the airway with intubation and mechanical ventilation + supplemental oxygen
Indications for intubation
Treat underlying cause of acute respiratory failure

Front 74

Criteria for Intubation

Back 74

Whenever the patient cannot maintain adequate ventilation on their own
When they cannot protect their airway from secretions & foreign matter
Intubate when there is risk to the airway such as an airway burn
Intubate if the patient likely will have ongoing respiratory distress i.e.. COPD with pulmonary contusion
Intubate if the patient has a head injury with a GCS <8

Front 75

Examples of Inadequate Respirations

Back 75

Cardiac Arrest
Respiratory Arrest (i.e.. Narcotic overdose)
Respiratory failure (i.e.. Status asthmaticus)
Severe lung disease (i.e.. Pulmonary contusion)
Traumatic Respiratory Distress
Neurologic Injury(CVA, Herniation, Post. Fossa lesion)

Front 76

Examples of Protection

Back 76

Prolonged unconsciousness
Inadequate gag reflex (i.e.. Drug overdose)
Airway encroachment (burn/bleeding)
Status epilepticus
Transfer of patients from institution to institution – concern of stability of airway en route

Front 77

Difficult ventilation:

Back 77

inability of a trained anesthetist to maintain the oxygen saturation >90% using a face mask for ventilation & 100% inspired oxygen, provided that the pre-ventilation oxygen saturation level was within the normal range

the need for more than three intubation attempts or attempts at intubation that last >10 min

clinical factors that complicate either ventilation administered by face mask or intubation performed by experienced and skilled clinicians

Front 78

TIming of adverse intubation sequellae in oxygenated vs .non oxygenated pts.

Back 78

oxy - 10 mins tolerated
non-ox - less

Front 79

complications occur in up to __% of patients requiring emergent intubation

Back 79

complications occur in up to 78% of patients requiring emergent intubation

Front 80

Incidence of esophageal intubation & aspiration ranges from 8 to __%, and 4-__% respectively

Back 80

Incidence of esophageal intubation & aspiration ranges from 8 to 18%, and 4-15% respectively

Front 81

Mallampatic class is devised by having patients sit up, open their mouth, and pose in the “________ position”(i.e.. Neck flexed with atlantoaxial extension) with the tongue voluntarily protruded maximally while the physician observes posterior pharyngeal structures

Back 81

Mallampatic class is devised by having patients sit up, open their mouth, and pose in the “sniffing position”(i.e.. Neck flexed with atlantoaxial extension) with the tongue voluntarily protruded maximally while the physician observes posterior pharyngeal structures

Front 82

Mallampati classes
ranks tongue size relative to mouth size
based on Faucial Pillars
Soft Palate
Uvula

Back 82

I: uvula fully visualized
II: uvula view partially obstructed
III: top of uvula visible
IV: uvula view obstructed

Front 83

Factors Predicting Difficult Intubation

Back 83

Mouth opening <7cm (three fingertips)
A cervical range of motion of <35 degrees of atlanto-occipital extension
A thyromental distance of <7cm (three fingerbreadths)
Large incisor length
A short, thick neck
Poor mandibular translation
Narrow palate(three finger breadths)
In the ED nearly 70% of patients undergoing RSI have either altered mental status or cervical spine collars in place that prevent the assessment of these predictive factors

Front 84

the 9 P's of Rapid sequence intubation

Back 84

seeslide 70

Front 85

Critically ill patients who require emergent intubation experience hypoxia, hypercarbia, & acidosis, which induce an extreme sympathetic outflow that is associated with tachycardia, labile BP, and increased myocardial contractility, and/or vasodilation, which result in postintubation hypotension

Back 85

Critically ill patients who require emergent intubation experience hypoxia, hypercarbia, & acidosis, which induce an extreme sympathetic outflow that is associated with tachycardia, labile BP, and increased myocardial contractility, and/or vasodilation, which result in postintubation hypotension

Front 86

ETT can provoke bronchospasm & coughing aggravating asthma, intraocular hypertension, and ICP

Back 86

ETT can provoke bronchospasm & coughing aggravating asthma, intraocular hypertension, and ICP

Front 87

Patients at risk for adverse events from airway manipulation benefit from the use of pre-induction drugs
Includes:

Back 87

Opioids
Lidocaine
B-adrenergic antagonists
Non-depolarizing neuromuscular blockers

Front 88

What opioid blunts the hypertensive response to intubation (40% incidence of hypertensive response compared with 80% in control subjects)

Back 88

Fentanyl

Front 89

Derivatives of fentanyl, _______ and ________ are more effective than fentanyl at blunting both the tachycardic and hypertensive responses to intubation

Back 89

Derivatives of fentanyl, sufentanil and alfentanil are more effective than fentanyl at blunting both the tachycardic and hypertensive responses to intubation

Front 90

A class 1B antiarrhythmic drug, has been used to diminish the hypertensive response, to reduce airway reactivity, to prevent intracranial hypertension and to decrease the incidence of dysrrhythmias during intubation

Back 90

lidocaine

Front 91

a rapid-onset short acting, cardioselective B-adrenergic receptor-site blocker that effectively mitigates the tachycardic response to intubation with an inconsistent effect on the hypertensive response

Back 91

Etomidate

Front 92

The combined use of ________(2mg/kg) and ________(2ug/kg) has a synergistic effect for reducing both the tachycardia and hypertension associated with tracheal intubation

Back 92

The combined use of esmolol(2mg/kg) and fentanyl(2ug/kg) has a synergistic effect for reducing both the tachycardia and hypertension associated with tracheal intubation

Front 93

Caution is needed with _______ in trauma victims who are at risk for hypovolemia and may require a tachycardic response to maintain BP

Back 93

Caution is needed with esmolol in trauma victims who are at risk for hypovolemia and may require a tachycardic response to maintain BP

Front 94

Induction agents

Back 94

Etomidate, Propofol, Thiopental, Ketamine

Front 95

Induction agent that does not affect BP

Back 95

Etomidate

Front 96

Adverse effects of etomidate include

Back 96

nausea, vomiting, myoclonic movements, lowering seizure threshold, adrenal suppression

Front 97

Where anatomically do Neuromuscular blocking agents work

Back 97

motor end plate

Front 98

These drug classes differ in that depolarizing agents ________ the acetylcholine receptor, whereas non-depolarizing agents ___________ ___________ the acetylcholine receptor

Back 98

These drug classes differ in that depolarizing agents activate the acetylcholine receptor, whereas non-depolarizing agents competitively inhibit the acetylcholine receptor

Front 99

Do neuroblocking agents affect BP?

Back 99

not directly

Front 100

The effects of succinylcholine on __________ balance and cardiac rhythm represent its major complications

Back 100

The effects of succinylcholine on potassium balance and cardiac rhythm represent its major complications