Rosen's > Dyspnea > Flashcards

Dyspnea Flashcards

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1
Q

Definitions: Allergy vs Urticaria vs Angioedema vs Anaphylaxis

A

Allergy: Hypersensitivity reaction after exposure to allergen

Urticaria: Systemic reaction to an allergen which can include hives, itchiness

Angioedema: Sudden swelling of a subq or cutaneous membrane due to vascular permeability and vasodilation
- can be allergy induced or not (ie med induced, hereditary)

Anaphylaxis: Life-threatening, type 1 hypersensitivity reaction to previously sensitized allergen
- non-immunologic to first time exposures likely due to mast cell degranulation (ie first time taking NSAIDs)

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2
Q

ROSENS BOX

4 types of Gell and Coombs immune reaction classification:

A

TYPE 1 = immediate hypersensitivity
- Binds to IgE –> mast cell degranulation –> minutes to desensitize
- most common

TYPE 2 = Cytotoxic antibody rxn
- Antigen binds to antibody (IgG/IgM) –> cell lysis
- ex: transfusion reaction ; Rh incompatibility

TYPE 3 = Immune complex mediated
- IgG/IgM binds to antigen –> forms immune complex –> deposits in vessel cells –> local infl –> infl and tissue injury
- Seen in SLE ; serum sickness

TYPE 4 = Cell mediated delayed hypersensitivity
- NO antibody involved
- lymphocytes see antigen and recruit more antigen
- ex: contact dermatitis, SJS, TEN

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3
Q

Risk factors for having anaphylaxis (2 categories, 12 total)

A

Age and Sex
- pregnant woman
- infants
- teenagers
- elderly
Outdoor times and env
- route (parenteral > oral)
- higher SES
- summer and fall
- Hx of atopy
- Emotional stress
- Acute infection
- Physical exertion
- Hx of mastocytosis

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4
Q

Risk factors for increased anaphylaxis severity and mortality (3 categories, 8 total)

A

Extremes of age
- Very young
- Very old
Comorbid conditions
- CVS dz
- Pulm dz
Others
- Concurrent use of HTN meds
- Concurrent use of alcohol, drugs, sedatives, tranquilizers
- Recurrent anaphylaxis episodes
- Upright posture at time of onset of sx

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5
Q

ROSENS box

Etiologic agents causing anaphylaxis by immunologic mechanisms:

  1. IgE- Dependent (9)
  2. IgE- Independent (4)
  3. Direct Mast Cell (4)
A

IgE-Dependent
1. Food
2. Medications (abx, NSAIDs, immunologiques)
3. Insect bites
4. Latex
5. Hormones
6. Anesthetics
7. RCM
8. Occupational allergies (plant protein, animal protein)
9. Aeroallergies (pollen, dust)

IgE-Independent
1. RCM
2. NSAIDs
3. Dextrans
4. Biologic agents

Mast Cell:
1. Physical factors (exercise, cold, heat)
2. Ethanol
3. Meds like opioids
4. Idiopathic

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6
Q

3 Criteria for diagnosing anaphylaxis

A
  1. Hypotension + exposure to known allergen
  2. Skin finding AND one of:
    a. Hypotension
    b. Resp issue
  3. 2 or more of:
    a. Hypotension
    b. Resp
    c. GI
    d. Skin
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7
Q

Common anaphylaxis allergens ( 6)

A
  1. Food
  2. Insect bites
  3. Contrast
  4. Exercise induced
  5. Idiopathic
  6. Drugs
    • worse in obesity, male, old age
    • Common abx = Penicillin
    • Common med = NSAIDs
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8
Q

Anaphylaxis Epi dose:

  1. Adults
  2. Kids
A
  1. Epi 0.3-0.5mg of 1mg/mL IM
  2. Epi 0.01mg of 1:1000 IM

q5-10 min

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9
Q

Anaphylaxis resus (6):

A
  1. Epi
  2. Fluid resus
  3. Steroids (mb in pts w asthma)
  4. Diphenhydramine (in Rosens but not great)
  5. If 2 doses of Epi not helping –> pressors like norepinephrine)
  6. Glucagon mb helpful in patients receiving beta blockers
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10
Q

Who is at increased risk of biphasic anaphylaxis reaction? (7)

A
  1. Hypotension
  2. Wide pulse pressure
  3. Unknown triggers
  4. Prior anaphylaxis
  5. Delayed epi admin
  6. > 1 dose of epi received
  7. Cutaneous S&S
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11
Q

Dispo of anaphylaxis:

  1. If pt completely asymptomatic
  2. When for everyone else?
  3. When does most biphasic reactions occur?
A
  1. After 1 hour
  2. after 4-6 hour if sx completely resolved
  3. After 6 hours (97% of cases)
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12
Q

Angioedema with urticaria treatment

A

H1-antihistamines (Cetirizine, loratadine)

2nd line: Short course of oral steroids

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13
Q

Angioedema without urticaria treatment?

A

Mainly supportive

Manage airway if needed

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14
Q

tPA induced angioedema treatment?

A

Antihistamines and corticosteroids

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15
Q

DDX of anaphylaxis? (4 categories, > 20 in Rosen’s box page 1424..)

A

Common
1. Urticaria
2. AsthmaE
3. MI
4. PE
5. Syncope
6. Anxiety/Panic attack

Flush syndrome
7. Alcohol
8. Mastocytocis

Shock syndrom e
9. Septic shock
10-13. All the other shocks

Others:
14. Hypoglycemia
15. HAE
16. ACEi angioedema
17. Red man syndrome
18. Pheo

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16
Q

RFs for death from asthma (9)

A

Hospitalization
- Hx of Near fatal asthma requiring intubation
- Hospitalization or ED visit for asthma in past year
Meds
- Using oral steroids
- Not using inhaled steroids
- Overusing SABA
- Poor adherence to drugs
ETC
- Psychosocial problems
- Psych disease
- Food allergy in patient with asthma

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17
Q

Asthma exacerbation treatment in ED, puffers and steroids:
- which puffers, how much of each?
- how much steroids?

A

Beta agonist: MDI > nebulizer
SABA
Under 20kg - 4 puffs q15min
Over 20kg - 8 puffs q15
○ No role for LABA
SAMA
ie Iprotropium

Steroids
Prednisone 50mg or dexamethasone
Methylpred IV (125mg/day) also recommended for peds

*If systemic corticosteroids, discharge home with 5-7 days of prednisone 50mg/day0po

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18
Q

Role of Mg2+ in asthma exacerbation:
1. Effect on airways?
2. Dose in adults? Kids?

A
  1. Relaxes bronchial smooth muscles
    Dilates airways
  2. Adults: 2g IV over 20 minutes
    Kigs: 40mg/kg/day
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19
Q

What is the role of HeliOx in asthma exacerbation?

A

Mixing helium with O2 reduces the gas’ density (as compared to nitrogen in ORA) so helps with airflow, reduces resp muscle work, dec wOB
○ Especially when heliox was used with SABA through nebulizers

Consider when:
- Severe airflow obstruct
- Hx of labile asthma
- Previous intubation
- Inability to adequately mech vent

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20
Q

6 indications to intubate asthmatic patient?

A
  1. Coma
  2. Altered consciousness
  3. Cardiac/resp arrest
  4. Paradoxical breathing pattern
  5. Refractory hypoxemia
  6. Failure of NIV
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21
Q

Preferred agent of induction for RSI of asthmatic patients? why?

A

Ketamine - bronchidilatory effect

Propofol also good but watch out for hypotension

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22
Q
  1. Pediatric ABC triangle?
  2. Pneumonic “TICLS” for appearance?
A
  1. Appearance, WOB, Circulation
  2. Tone
    Interactiveness
    Consolability
    Look/Gaze
    Speech/Cry
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23
Q

Difference between resp distress VS resp failure in kids?

A

Resp distress - S&S of abnormal respiratory pattern, a clinical diagnosis

Resp failure - Inability of lungs to oxygenate or remove CO2, an objective diagnosis

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24
Q

5 clinical signs of resp failure in paediatrics?

A
  1. Grunting
  2. Decreased breath sounds
  3. “Normal” breathing but worsening clinically
  4. LOC change
  5. Color change
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25
3 ABG Criteria for resp failure? - PCO2 level - PO2 level - pH
PCO2 > 50 mmHg PO2 < 60 mmHg pH < 7.35
26
5 DDX of upper airway and 5 ddx of lower airway dz in paediatrics?
Upper Airway: 1. Croup 2. Epiglottis 3. FB 4. RPA 5. Tonsilitis Lower Airway: 1. Asthma 2. Pneumonia 3. CF 4. Bronchiolitis 5. PE 6. Sickle cell crisis
27
5 ddx of non-pulmonary/non-cardiac causes of respiratory distress?
1. Increased cerebral pressure 2. Toxic encephalopathy 2. DKA 3. Lactic acidosis 4. Toxic shock syndrome
28
Bronchiolitis: 1. Most common virus? Other ones (2)? 2. Best treatment? 3. Five complications?
1. RSV ; Rhinovirus, Influenza 2. O2 support and Hydration! NO MEDS or PUFFERS or STEROIDS! No evidence 3. Otitis Media Sepsis Apnea Resp failure Dehydration
29
3 treatments with equivocal evidence for treating bronchiolitis?
1. Epinephrine nebulization 2. Combined epi and dex 3. Nasal suctioning
30
Bronchiolitis admission criteria? (6)
1. Severe resp distress 2. Supplemental O2 required 3. Cyanosis/Apnea 4. Dehydration/dec PO intake 5. "high risk" infant 6. Parents not coping
31
RFs for admission of bronchiolitis? (4)
1. < 12 weeks 2. Prematurity < 35 weeks 3. Immunodeficient 4. Cardiopulm dz
32
Bronchiolitis prophylaxis? Who gets it? (3)
Palivizumab - Chronic lung dz Congenital Heart dz Premature
33
What is the pathophys of CF?
Autosomal recessive mutation in CFTR gene - leading to defect in chloride transport and dec ciliary clearance, thickened mucus, bacteria adherence
34
2 overarching features of CF?
1. Pancreatic insufficiency 2. Chronic infections
35
Cystic Fibrosis: 1. 5 Bacteria causing CF exacerbation? Which has the highest mortality? 2. Treatment in ED? 3. Abx choice?
1. Staph aureus (+/-MRSA) Non-typeable H. influenza Sternotrophus Maltophilia Pseudomonas Burkholderia Cepacia (BAAAAD) 2. Bronchodilators and N-Acetylsysteine puffers ; Chest physio ; Abx 2. Beta-lactams & Aminoglycoside * Cover for pseudomonas bc 98% colonize it by the age of 3!!
36
Sore throat red flags (3 categories)
Suspicion for deep neck space infection ie. truisms, severe pain, large mass Toxic patient Signs of impeding airway obstruction like drooling, stridor, tripping
37
DDX stridor (10)
Choanal atresia RPA PTA Adenotonsilar enlargement Ludwig's Angina Neoplasm FB Trauma Laryngomalacia Croup Epiglottis Tracheitis Laryngospasm
38
Most common cause of congenital stridor?
Laryngomalacia
39
Laryngomalacia: 1. Pathophys? 2. Stridor worsens when..? (4) 3. What age does it come on? What age is it resolved? 4. Dx? Treatment? 5. Indications for surgery (4)
1. Incomplete development of laryngeal cartilage --> epiglottis falls on it and causes stridor 2. Prone, neck flexion, crying, feeding 3. A few weeks after life ; resolves by 2 years 4. Awake endoscopy ; usually self resolves 5. Severe Feeding difficulty Apnea Cyanosis
40
Croup: 1. Age range? 2. Viruses? 3. Sx? 4. When is it worse? (2) 5. Treatment?
1. 6 months - 6 years 2. Parainfluenza virus (most common) Influenza A & B Rhinovirus 3. Viral prodrome --> 12-48 hours later, Barky cough, hoarse voice, biphasic stridor 4. With Crying At night 5. Dexomethasone 0.6 mg/kg Aerosolized epinephrine - to those w stridor at rest & resp distress .. must be watched for 2-3 hours at rest to ensure no rebound
41
Bacterial tracheitis: 1. What is it? 2. Most common bacteria? 3. Diagnosis? 4. XR finding? 5. Treatment?
1. Superinfection/ complication of croup! *Most common cause of resp failure from infectious stridor (especially since the HIB vaccine and steroids for croups have been used) 2. Staph aureus /MRSA .. but others can cause it too 3. Clinical! Confirm with direct laryngoscope 4. STEEPLE SIGN! "Shaggy" trachea 5. Abx (Cftx + Vanco) +/- endoscopic debridement
42
Classic triad of FB aspiration?
1. Cough 2. Wheeze 3. Decreased unilateral breath sound *This is v rare
43
Foreign body gold standard for treatment?
Bronchoscopy *also good for treatment
44
Epiglottitis 1. What is it? 2. Bacteria? 3. Diagnosis?
1. Invasive bacteria infl of epiglottis 2. H influenza B (historically) H influenza A Streptococcus Staph aureus 3. Lateral neck xray 4. Airway management!!! IV abx etc.
45
Adult epiglottis 1. Causes 2. RFs 3. S&S 4. Dx 5. Tx
1. S. pneumo S. Pyogen S. Aureus 2. Infection Thermal burn Trauma Cocaine 3. Smoking Drugs HTN DM ESRD IC 4. Toxic appearance Stridor Drooling Resp distress + pharyngitis, dysphagia etc 5. Direct visualization Lateral neck XR and CT also 6. Cftx + Vanco + Nebulized epi + systemic steroids + bronchodilators + consider intubation
46
Epiglottitis neck XR findings? (5)
1. "Thumbprint sign" - enlarged epiglottis 2. Lack of air in vallecula 3. Thickened aryepiglottic folds 4. Distended hypopharynx 5. Straightened C spine *Only 30-60% abnormal!
47
PeriTonsillar Abscess 1. Pathogens 2. RFs/causes (7) 3. Investigation 4. Tx (6)
1. Polymicrobial Fusobacterium Necrophorum 2. Tonsilitis GAS Pharyngitis Mono Tonsil stones Dental procedures Smoking 3. Monospot 4. I&D Abx Cftx + Flagyl Analgesia Dex Observe to ensure no complications Outpatient FU
48
RetroPharyngeal Abscess 1. Causes (10) 2. Dx: Gold standard + alternatives 3. Tx
1 . Pharyngitis Tonsillitis PTA AOM Dental infections FB Trauma Ludwig Angina Oral procedures Endoscopy 2. CT gold standard XR and US also able 3. Tazo + Vanco (polymicrobial) Airway management! ICU/ENT dispo
49
Diphtheria
Diphtariae URI, fever, malaise, Greyish membrane on palatines Dx with culture Tx with Diphtheria antitoxin, PenG
50
Mono 1. Pathogen 2. Dx 3. Tx 4. Who gets steroids?
1. EBV 2. Monospot most sensitive 3. Supportive 4. If sever complications ie. airway obstruction, liver failure, hemolytic anemia
51
Most common source of bleeding in minor hemoptysis? Major hemoptysis?
Minor = tracheobronchial capillaries Major = bronchial arteries
52
10 causes of hemoptysis (VINDICATE) Most common?
V - AV malformation I - Infection (TB, pneumonia) N - Neoplasm D - Drugs (cocaine) I - Iatrogenic C - Congenital A - Lupus, vasculitis, bronchitis T - Trauma E - Environmental *Most common = neoplasm
53
Diffuse alveolar hemorrhage 1. What is it? 2. Causes
1. Bleeding into alveolar space due to capillaries or vessels rupturing 2. Infection, vasculitis, SLE, cocaine
54
Hereditary Hemorrhagic Talengectiasia: 1. What is it? 2. Most common areas? 3. What is the biggest concerns? 4. What can they not do? (3)
1. Inherited disorder that causes arteriovenous malformations (AVMs), to develop between arteries and veins. 2. Nose, lungs, brain and liver 3. air emboli that can travel to brain!! 4. Scuba dive, prophylactic abx before procedures, not take NSAIDs!
55
2 definitions of massive hemoptysis
1. > 100mLs of blood loss in 24 hours 2. Any hemop that causes hemodynamic instability OR causes resp distress
56
Intubation of massive hemoptysis:
1. Consider awake intubation to preserve cough 2. Consider right main bronchus ETT with Fogarthy catheter to pass by to left side to tamponade 3. Advanced intubation with double lumen
57
Causes of early tracheal bleed (3) Causes of late treach bleed (3)
Early: - Manipulation of tube - Bleeding at surgical site - Operative injury to vessel Late: - Infection - Granulation tissue - Trachoinominnate fistula
58
Tracheoinnominate fistula bleed: what do you do?
Call for help, ABCs Overinflated the cuff --> intubate from above --> remove trach --> digital compression of the innominate artery
59
GOLD definition of COPD
A common, preventable and treatable disease that is characterized by persistent respiratory symptoms and airflow limitation that is due to airway or alveolar abnormalities usually caused by significant exposure to noxious particles or gases.
60
COPD RFS (6)
- Cigarette smoking BIGGEST RF - Male - Age > 40 - Indoor pollution - Occupational exposures - Genetic alpha-1 antitrypsin deficiency
61
GOLD criteria COPD severity
Mild = FEV1 > 80% Moderate = 50 - 80% Severe = 30 - 80% Very severe = < 30%
62
ROSENS BOX: Classification of resp failure in COPD - No resp failure (5) - Acute resp failure (5) - Severe failure (3)
No resp failure - WOB: normal - tachypnea: mild, 20-30 - Hypoxemia: mild, responsive to nasal canula - Hypercapnia: none - Baseline mental status Acute resp failure - WOB: increased with accessory muscle use - tachypnea: sig, >30 - Hypoxemia: responsive to FiO2 < 35% - Hypercapnia: 50-60 & pH > 7.25 - Baseline mental status Severe: - Hypoxemia FiO2 > 35% - PaCO2 > 60% or pH < 7.25 - AMS
63
Causes of COPD exacerbation
1. Bacterial: S. pneumo, H.influenzae, Pseudomonas 2. Viral: RSV, Rhinovirus, Influenza 3. Environmental 4. Med non-compliance
64
COPD patient ECG?
1. P pulmonae (Peaked t waves, low QRS voltage, poor R wave progression from precordial leads) 2. Dysrhythmia 3. RVH
65
COPDE management in ED
- SABA and SAMA back to back - Corcicosteroids - NIPV
66
Exclusion criteria for NIV ( 8)
1. Resp arrest 2. CVS instability 3. Upper airway obstruction 4. Aspiration risk 5. Aggitated patient 6. Craniofacial trauma 7. Recent facial surgery 8. Non fitting mask
67
COPD GOLD criteria for admission (6)
1. Sig worsening sx 2. Bad response to ED tx 3. Sig comorbidities 4. Worsening hypoxia, inc CO2 5. Failed outpatient management 6. Social situation bad
68
COPD, BiPAP: 1. Indications (3) 2. Contradictions (4)
Indications: - Resp acidosis Co2>45 & pH < 7.35 - Severe days - Persistant hypoxemia dispute supplamental O2 Contradictions: - Active vomiting/high risk aspiration - Resp arrest - Facial trauma - Depressed mental status
69
COPD, intubation: 1. Indications (7) 2. Contradictions (2)
Indications: - Not tolerating NIV - NIV failure - diminished consciousness - Resp/cardiac arrest - Not removing secretions - Hemodynamic inst w/o respond to fluids - Hypoxemia not corrected by NIV Contraindications - Appropriate for NIV - DNR/DNI
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