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Flashcards in Pulmonary and CP Deck (81)
1

approach to pt with mild to moderate Asthma attack

(3)

 Hand held nebulizer – asap Albuterol, Atrovent

 Oral Prednisone (60mg) PO (as good as IV initially)

 Peak flow (PEFR) after each neb tx, repeat VS, reassess

 Usually no need for labs, CXR, EKG, ABG, etc

2

Discharge

 Walk ‘em, assure f/u, return precautions
--> have them speaking mary had a little lamb her fleece was white as snow

 Oral steroid burst (60mg x5d or tapered dose Rx), inhaled steroid Rx

3

asthma pt can't go home if

 Not responding to treatment, worsening

 Hypoxic - ambulatory pulse ox <95%

 PEFR not improved to 65- 70% predicted

 ED visit in past 3 days for same

 Exacerbation during steroid burst

4

hallmark of asthma attack

bilateral!

if not--> another dz process

5

Other than wheezing what would we likely see in a pt with an asthma attack


Dyspnea, cough, chest “tightness”

Pronged expiratory phase, I:E ratio 1:3 or 4

Tachypnea, tachycardia, HYPOxia, HYPERcarbia

Poor peak expiratory flow measurements (PEFR)

6

how do you elicit a prolonged expiratory phase

blow out the cake with 100 candles
will hear prolonged exasperation

7

what is a nl peak flow

Poor peak expiratory flow measurements (PEFR)
650 or 700 is normal

8

why do we see asthma exacerbations most commonly in the ED

Med non-compliance, viral illness most common reasons

9

what other pts wheeze

CHF
PE
COPD

is the person is over 40 and does not have a dx of asthma WATCH OUT

10

essential questions for pts with asthma

have you had a fever?
have you had any trauma?
have you been sick?
have you had this before?

11

what is the neb treatment for asthma

albuterol neb 2.5 mg

once, 3x q20min or 10ml/1hr

12

COPD exacerbation will look like (VS)

BP 170/95,
P 120,
RR 32/min, (not good!)
T 97

pulse ox 93% on 4L nasal canula. 3-4 word sentences, sweating, insists on sitting upright, leaning forward.

13

treatment goals for COPD

reverse hypoxia, reverse hypercarbia, restore effective ventilation

The retention of CO2 is what brings these people down

pump has to work
alveoli have to work
need to get it out

14

reasons for COPD exacerbations

1. Disease progression

2. Med non-compliance, out of home O2

3. Infection - viral, bronchitis, pneumonia

4. Cardiac - pump
failure/impairment, arrhythmia

5. Metabolic acidosis, other illness on top

6. Exposure/environment

7. Sedation, drugs

15

what do we see on a COPD CXR

Hyperexpanded lung fields, narrow cardiac silhouette, flat diaphragms, blunted costophrenic angles

16

what labs would you want in a COPD exacerbation pt

CXR, lung/cardiac US, EKG, monitor, labs

17

TX COPD

 Continuous nebulizer treatments
Beta 2 agonists (10mg over 1h)
Inhaled anticholinergics
 Oral steroids, IV if admit
 Antibiotics if appropriate
 Assisted ventilation - NIPPV

18

antibiotic commonly used in COPD pts

doxy

they get the weird bugs

19

when can you NOT send a COPD pt home

 Not responding, worsening symptoms/signs
 Mental status changes
 If they require a bipap
 Hx recent severe exacerbations/intubation
 Older, co-morbidities
 New arrhythmia
 Uncertain of diagnosis
 Poor ambulatory pulse ox
 Poor home support

20

presentation of pneumothorax

elevated RR
elevated pulse
94% Room air
sudden

21

focused Hx for pneumothorax

have you had this before?
cardiac and pulm ROS
PMH
trauma? syncope?

22

Pulmonary ROS

Cough? Sputum? Hemoptysis?
o Coughing up blood?
• Shortness of breath (SOB = dyspnea)? • Wheezing?
• Pleurisy?

23

Cardiac ROS

Chest pain?
• Palpitations?
• Dyspnea on exertion DOE? o SOB on exertion?
• Orthopnea?
o SOB when lying down?
• Paroxysmal nocturnal dyspnea PND?
o Do you awake in the middle of the
night and feel like you have to run
to the window to get air?
• Leg edema?
o Swelling in legs?
• Hx of cardiac problems? (HTN, MI, CHF,
rheumatic fever, heart murmur)?
o **Move to PMH if positive
• Ever had/last EKG?
o **Move to HM: Screening
• Ever had/last heart tests (echo, stress
tests)?
o **Move to HM: Screening
• Cardiac procedures (cath, stent)
o **Move to PMH: Surgeries if yes

24

What do you do for suspected pneumothorax

i. IV, O2, monitor; EKG, tx pain
ii. CXR – search edges
1. +/-Expir film, lateral decub; deep sulcus sign if in bed
iii. Bedside ultrasound

looking for absence of “comet tailing”; the friction of pleural sliding

Shock? Or stable now?
1. Can deteriorate quickly
2. Could be obstructive shock
v. Primary or Secondary?
1. Primary pneumo --> spontaneous
2. Secondary pneumo --->a result of something

chest CT
surgery consult

25

Tx for pneumothorax

1. Treatment depends on size
Pigtail catheter w/ Heimlich valve
Chest tube

2. Small, primary pneumos (<15% total lung) in select cases, a stable patient can go home if:

26

when can a pneumothorax go home


with a pigtail

Not a secondary pneumo
b. Stable vitals after 3-4hrs
c. Repeat CXR with no enlargement
d. Pt is reliably able to return in 12-24hrs for repeat CXR
e. If catheter re-expansion
i. Stable x6hrs
f. Surgical consult agrees

27

tension pneumothorax is dx

CLINCALLY

pt will die if not treated

28

Pt presentation of pneumothorax (5)

Pt with trauma to the chest

1. Severe dyspnea, sudden change in VS/LOC
2. *Decreased breath sounds affected side
3. *Hypotension
4. *Distended neck veins
5. *Tracheal shift (late)

29

what is the Tx for tension pneumothorax

iv. Needle thoracentesis: 2nd ICS at MCL

with 16 gauge at second intercostal space mid-clavicular line

v. Follow with chest tube immediately

30

a. A 54yo woman, hx of breast CA, BIB family. The pt has “not left her bed” and has been c/o chest pain for the past 2 days and seems to be “breathing fast”. Family states chemo/radiation ended 4mos ago. Patient is thin, appears ill, is not talking.
Vitals: BP 108/60, P 110, RR 28, T 99.3 (not a fever), 93% on room air

what is supected in the pt and why

Don’t know yet DDx? PE, sepsis, malnutrition/dehydration, is she in hypovolemic shock?

PE and pulmonary effusion are at the top b/c of hx of chemo

BP is low
P 100
RR 28
T 99.3
93% on room air

IV, OT MONITOR

31

Pulmonary Effusion workup

i. IV, O2, monitor, pain control, labs
ii. CXR; Lateral decubitus film – does it layer out?
iii. Bedside ultrasound - see fluid, guides tap – also check for pericardial effusion
iv. Chest CT - gold standard

32

if you have a pulmonary effusion you need to look for

pericardial effusion -triple scan

33

what can a CT tell us about a pulmonary effusion

1. Excellent for small effusions, other dx’s
2. CT guided thoracentesis if loculated – doesn’t layer out
3. Effusions can be infectious, malignant, reactive, chronic, post-surgical, traumatic

34

TX for pleural effusion

1. Sick? Is this shock? Fever?
2. Triple scan US: fluid status, pericardial effusion
3. US guided Thoracentesis
Diagnostic and therapeutic
Slow removal of fluid - ultrasound guided`
No more than 1000 - 1500ml
To avoid re-expansion pulmonary edema
CXR after to check for pneumothorax
4. Pleural fluid analysis

35

Thoracentesis for pleural effusion

diagnostic and therapeutic

36

who are you worried about in flu season

Young, old, immunocomp, recent surg/hosp, lung Dz

37

who gets a CXR with the flu

1. Hypotension/tachy/tachy, hypoxic, lung findings
2. No viral syndrome sx’s, worsening (We are worried about PNA)
sxs for more than 2 weeks

38

who get moved to maintain to the ED

Abnormal VS, chest pain, young/old, risks, look sick

39

Which Hx/PE findings really make a difference in a pt with suspected flu

1. ROS: SOB, DOE, hemoptysis, leg edema/pain, syncope
2. PMHx (cardiac, lung dz, DM, steroids), SH (etoh, homeless)
3. VS, diaphoresis, new wheezes, rales, edema, rash

40

Who has the flu vs. who has pneumonia, other dx??

1. Bacteria/pneumonia is very narrow minded and tends to stay in one spot
2. Flu gives you symptoms all over – malaise, sore throat, fever, vomiting, maybe diarrhea (viruses affect a lot of different systems)

41

1. CURB65

helps predict mortality in a person with pneumonia

CONFUSION
BUN
RR
BP
OVER 65

42

TX for pneumo

v. Abx:
Azithro mostly

Levo?, Doxy

43

MCC of hemoptysis

1. Pneumonia = MCC
2. Coumadin
3. Tuberculosis
4. Cancer
5. Pulmonary embolus
6. Hematemesis?
7. Nasal, dental, oral source?
8. Trauma

44

how does hemodynamically stable help us figure out hemoptysis
1:00hr

iii. Hemodynamically stable?
Hemodynamically unstable patients don't have enough pressure in the circulatory system to keep blood flowing

Pale and cool skin
Diaphoresis (sweating)
Fatigue
Very fast or very slow pulse (fast can be either a reaction to or a cause of instability; slow is almost always a cause)
Low blood pressure (very late sign)
Shortness of breath (not enough blood getting to the lungs)
Chest pain (could be related to inadequate blood flow in the heart)
Confusion (probably comes after the blood pressure drops)
Loss of consciousness (syncope, which is bad)

45

what diagnostic tests should we be running for hemoptysis

 ABC’s, vitals; IV(s), O2, monitor
 Hx: Onset? Chest pain? SOB? Weight loss? Fever? Trauma? Coumadin? CAM?
 PE: Usual suspects + look for non-pulmonary source

 CXR, EKG, Labs, lactic acid, PT/INR. Type and screen/cross?
 Chest CT if significant, stable

 If very significant, ongoing: a big airway concern (blood is coming from the airway). Make a plan

everybody needs to be in the room. need a bronch

 Pulmonary consult: bronchoscopy

46

f. HIV w/ infiltrates-what diagnostic tests would you want


CXR
Labs:
lactic acid
LDH-helps predict severity
cultures
HIV labs: CD4 count, viral load

47

when is an HIV pt considered immunocompetent

1. CD4 >200 = immunocompetent

48

i. Clinical Presentation of TB

Cough, fever, weight loss, fatigue, night sweats, pleuritic chest pain, dyspnea and hemoptysis.

49

Risks for TB

Classic sx’s, endemic area of origin - travel

Risks: immunocomp, incarcerated, known exposure, homeless, EtOH

50

3. Lung exam in a pt w/ TB

can't be diagnosed
variable

need CXR and labs

51

CXR presentations of TB

a. Infiltrates/consolidation
b. Reactivation favors upper lobes
c. Pleural effusion
d. Cavitary lesions
e. Calcifications
f. Miliary pattern

52

what do you do with TB in the ED

if in respiratory distress--> ADMIT

if high risk (+ PPD, hx of exposure, alcoholic, incarcerated, form endemic area)

if your CXR has ANY infiltrate of effusion --> ADMIT

53

positive PPD hx with clean CXR and sxs of TB

ADMIT

54

+PPD, CXR, NO sxs

home

PCP or TB coordinator f/u and intiate tx
ED does not initiate tx

55

a. A 73yo F w/ Hx HTN, DM, BIB ambulance c/o 2d of increasing “breathlessness”, now with slight exertion, and chest “tightness”. She looks pale, anxious and uncomfortable.

Vitals: BP 182/112, P 118, RR 28, afebrile, pulse ox 94% on non-rebreather mask.

what's your ddx

 CHF
 AMI/ACS
 PE
 Pericardial effusion
 Infection
 Pleural effusion
 Renal failure
 Cancer

56

A 73yo F w/ Hx HTN, DM, BIB ambulance c/o 2d of increasing “breathlessness”, now with slight exertion, and chest “tightness”. She looks pale, anxious and uncomfortable.

what do you do for this pt

Begin with: IV, O2, monitor, EKG, CXR, Triple scan US

Labs, lactic acid, troponin, UA, Tox screen
Careful Hx & PE when stable

she's probably acidotic and we already know where we are going to start with her
BNP is $$$$$

57

TX for CHF

1. LMNOP-N

Lasixs
Morphine
NTG
O2
Position
NIPPV




2. -Diuretics: Lasix
3. -Vasodilators – NITRO IV reduce preload, afterload:
4. Morphine +/-, Nitrates
5. -Oxygen, Position
6. -NIPPV is awesome
7. -US better than BNP in ED unless Dx uncertain
8. -Admit all new CHF – search for cause
9. -Admit moderate, severe, recurrent, unstable
10. B lines on lung U/S

58

how should we think about CHF

structural functional inability to fill and pump
can be acute or chronic

acute: flash pulmonary edema, L-sided MI, HTN emergency, valve rupture

chronic: HTN, valve dz, CAD--> cardiomegaly, mitral regurg

59

three questions we need for CHF

R or L or both
systolic or diastolic
high or low output failure

60

left sided Heart failure looks like

DOE
cough
fatigue
orthopnea
PND
rales
S3 gallop

61

right sided looks like

JVD
peripheral edema
hepatomegaly
anascara

62

systolic looks like

can't squeeze enough

63

diastolic HF looks like

can't relax to fill

64

low output failure

common chronic CHF low EF

65

high output failure

compensating for demand
thyroid storm
anemia etc

66

when do we NOT GIVE NITRO for CHF pt

right sided inferior MI
viagra
tamponade
aortic stenosis
or hypovolemia

67

47 yo female self presents to the ED c/o increasing DOE and dizziness for 1 week. No PMH. Triage vitals: BP 132/88, P 104, RR 20, afebrile, pulse ox is 98% on ra.

pulse a little high
RR pretty high

CXR-->good
Pulse OX--> good
get a Hgb 6.2 hct 20%

68

when do we see anemia sxs and what do they look like

when compensation fails

i. When compensation fails = Sx’s: DOE, dizzy, weak, malaise, palpitations, chest pain, syncope

69

tx for symptomatic anemia

blood

need occult blood test
MCC- menstration
need CA workup

So...why is this patient anemic?? Melena? Menstrual? Cancer? Renal Failure? Iron? Macro- or Microcytic?

70

40yo F c/o 4 hours of sharp, L-sided chest pain, worse with deep breath. “My breath feels short”. Denies fever, chills, cough, DOE, palps, trauma. Hysterectomy 3wks ago. Well yesterday, no other PMHx. Looks uncomfortable.

thoracic aortic dissection

71

RF for thoracic aortic dissection

Marfan’s, Ehlers-Danlos, connective tissue dz, pregnancy, syphilis, family hx of sudden death at young age – all are risk factors

72

classic symptoms for thoracic aortic dissection

sudden “tearing/ripping” w/ SOB, HTN. Jaw, neck, chest - pain evolves, changes.

Migrating pain above and below the diaphragm; GI complaints – n/v/d

Dizziness, near-syncope, neuro sx’s common (extremities can get weak)

73

a. 40yo F c/o 4 hours of sharp, L-sided chest pain, worse with deep breath. “My breath feels short”. Denies fever, chills, cough, DOE, palps, trauma. Hysterectomy 3wks ago. Well yesterday, no other PMHx. Looks uncomfortable.
i. VS: 128/80, P 112, RR 20, T 99, O2 96% ra

PE

WELLS score is 6

74

#1 risk for PE

previous DVT/PT

75

must consider a PE in everyone with

CP

76

WELLS SCORE

 Signs/Sx’s DVT - 3pts
 PE #1 Dx – 3pts
 Heart rate >100 - 1.5pts
 Immobilization 3 days or surgery <1mo - 1.5pts
 Hx proven PE/DVT-1.5pts
 Hemoptysis – 1pt
 Active malignancy – 1pt

77

three tier and two tier model for WELLS

 Low prob = <2 pts (1.3%)
 Moderate = 2-6 pts (16.2%)
 High prob = >6 pts (37.5%)

 Two tier model
 “PE Unlikely” = 0-4 pts (12%)
 “PE Likely” = >4 pts (37%)

78

criteria for PERC-ing a pt

(do this for low risk)

must answer YES to all of them

• Age <50
• Pulse <100
• SaO2 >94%
• No unilateral leg swelling
• No hemoptysis
• No recent trauma or surgery
• No hx prior DVT or PE
• No hormone use

79

when do we do a D dimer

low to moderate risk that can't be PERC out

80

i. In every patient with chest pain, you must consider the “Big 6” – “cannot miss” diagnoses

(2 A’s, 3 P’s, a B)


ii. AMI/ACS/USA
iii. Thoracic aortic dissection
iv. Pericarditis/pericardial effusion
v. Pulmonary embolus
vi. Pneumothorax
vii. Boerhaave’s (espohageal
rupture/pneumomediastinum)

81

clubbing is most commonly seen with

chronic bronchitis and people that have had surgery