Respiratory and EENT Emergencies

What are the three components of the primary assessment (ABCs) when triaging a respiratory patient?

Airway, Breathing, and Circulation.

How does altered mental status help assess circulation in a respiratory patient?

Agitation signals hypoxia, while somnolence signals hypercapnia.

What clinical signs require bypassing a lengthy history for immediate resuscitation?

Inability to speak in full sentences, "silent chest," or depressed mental status.

What is the key clinical clue for a Pulmonary Embolism (PE) life threat?

Acute dyspnea, pleuritic chest pain, and tachycardia.

What diagnostic modalities and immediate actions are used for a Pulmonary Embolism?

CTPA or POCUS (McConnell's Sign); immediate anticoagulation or thrombolysis.

What are the key clinical clues for a Tension Pneumothorax?

Hypotension, absent breath sounds, and tracheal deviation.

What is the immediate emergency department action for a Tension Pneumothorax?

Needle decompression or finger thoracostomy.

What are the key clinical clues and immediate actions for severe Asthma or COPD?

Silent chest, profound wheezing, tripod positioning; continuous bronchodilators and BiPAP.

What chest X-ray finding and immediate action are associated with ARDS or severe Pneumonia?

Bilateral infiltrates; lung-protective intubation.

What clinical clues define Cardiac Tamponade, and what is its immediate treatment?

Beck's Triad (hypotension, JVD, muffled heart sounds); immediate pericardiocentesis.

How does symptom onset differentiate a Pulmonary Embolism/Pneumothorax from Pneumonia/Effusion?

PE and pneumothorax present suddenly; pneumonia and effusion present gradually.

What do orthopnea and paroxysmal nocturnal dyspnea (PND) typically suggest?

Decompensated heart failure or severe COPD.

What is the threshold for massive hemoptysis, and what are its main causes?

Over 500 mL in 24 hours; caused by malignancy, TB, PE, or mitral stenosis.

What risk factors should be assessed for hypercoagulability in a dyspneic patient?

Recent surgeries, long travel, active malignancy, hormone replacement, or DVT/PE history.

Why should a clinician be cautious with pulse oximetry in carbon monoxide poisoning?

It can show a falsely high oxygen saturation (SpO2).

What does localized wheezing suggest compared to diffuse wheezing?

Localized suggests a foreign body or malignancy; diffuse suggests asthma or COPD.

What does stridor indicate on physical examination?

Critical upper airway narrowing.

When is a Venous Blood Gas (VBG) preferred over an Arterial Blood Gas (ABG)?

For trend monitoring of pH and pCO2 in asthma or COPD.

When should an Arterial Blood Gas (ABG) be reserved over a VBG?

For precise oxygen estimation in ARDS or profound shock.

What ECG findings indicate right ventricular strain in a suspected PE?

S1Q3T3 pattern and T-wave inversions in leads V1 to V4.

What are the three classic pathognomonic ultrasound signs looked for in the BLUE Protocol?

Lung sliding (rules out pneumothorax), B-lines (pulmonary edema), and consolidations (pneumonia).

What is the triad of airway obstruction in the pathophysiology of asthma?

Bronchospasm, airway edema, and mucus plugging.

What are the physiological consequences of air trapping (auto-PEEP) in severe asthma?

Increased residual volume, increased work of breathing, and impaired venous return.

What does a "silent chest" signal in an acute asthma exacerbation?

Impending respiratory failure due to critically poor airflow.

How is asthma severity classified using Peak Expiratory Flow Rate (PEFR)?

Mild-moderate is over 50% predicted; severe is under 50% predicted.

What is pulsus paradoxus, and what does it reflect in asthma?

Systolic blood pressure drop over 10 mmHg during inspiration; reflects profound pressure swings.

What are "Red zone" steps in asthma, indicating <50% PERF?

Severe obstruction

Requires immediate treatment

Frequent bronchodilators

Systemic steroids

O2 as needed

What is the target oxygen saturation range for a patient with an asthma exacerbation?

Between 93% and 95%.

Why is a normal or rising pCO2 (over 40 mmHg) in a tiring asthmatic alarming?

It indicates respiratory muscle fatigue and impending respiratory failure.

What are the clinical indications for ordering a chest X-ray in an asthmatic?

Fever/leukocytosis, asymmetric breath sounds/subcutaneous emphysema, or first-time wheezing.

What is the first-line pharmacotherapy toolkit for a mild to moderate asthma exacerbation?

Inhaled albuterol (SABA), inhaled ipratropium bromide (SAMA), and systemic corticosteroids.

What is the dose and administration limit for inhaled ipratropium bromide in asthma?

0.5 mg every 20 minutes, up to 3 doses.

What are the systemic corticosteroid dosing options for acute asthma?

Oral prednisone 50 mg or IV methylprednisolone 60 to 125 mg.

What is the role of IV Magnesium Sulfate in severe asthma?

It acts as a smooth muscle relaxant; dose is 2 g over 15-20 minutes.

When is IM Epinephrine indicated in asthma, and what is the dose?

For severe, refractory bronchospasm; dose is 0.3 mg of 1:1000 dilution.

Why is Ketamine the preferred induction agent for rescue intubation in asthmatics?

It possesses bronchodilating properties.

What mechanical ventilator settings are required for an intubated asthmatic?

Low respiratory rates and low tidal volumes to allow exhalation and prevent auto-PEEP.

What are the discharge criteria for a patient after an asthma exacerbation?

Symptom resolution, PEFR over 70%, normal room-air saturation, and reliable follow-up.

What is included in the standard discharge prescription bundle for asthma?

Albuterol MDI, 5-day course of oral Prednisone 50 mg, and an inhaled corticosteroid.

When must an asthma patient be admitted to the hospital?

PEFR under 50% despite therapy, persistent acidosis, or rapid decline/prior intubation history.

How do typical age and smoking history differentiate COPD from asthma?

COPD is usually over 50 with heavy smoking; asthma is usually young with infrequent smoking.

How do sputum production and reversibility differentiate COPD from asthma?

COPD has fixed airflow and copious sputum; asthma has reversible inflammation and minimal sputum.

What are the physical signs of hypercapnia in a COPD patient?

Flushed skin, bounding pulses, asterixis, and progressive somnolence.

How does VBG analysis differentiate chronic compensated hypercapnia from acute respiratory acidosis?

Compensated has high pCO2 with normal pH; acute acidosis has high pCO2 and pH under 7.35.

What is the target oxygen saturation for a COPD exacerbation, and why?

88%-92%; over-oxygenation can worsen hypercapnia via the Haldane effect.

What is the first-line bronchodilator nebulizer treatment for a COPD exacerbation?

Duoneb (Albuterol 2.5 mg and Ipratropium 0.5 mg).

What are the three Anthonisen criteria that indicate antibiotic use in COPD?

Increased dyspnea, increased sputum volume, and increased sputum purulence.

What are the first-line oral antibiotic options for a COPD exacerbation?

Azithromycin, Doxycycline, or Amoxicillin-clavulanate.

What are the clinical indications for initiating BiPAP in a COPD patient?

pH 7.35 or lower, severe dyspnea with muscle fatigue, or persistent hypoxemia.

What are the clinical benefits of using BiPAP in COPD exacerbations?

Reduces work of breathing, counteracts intrinsic PEEP, and lowers intubation and mortality rates.

What are the absolute indications for mechanical intubation in a COPD patient?

BiPAP failure/intolerance, arrest, profound cardiovascular instability, or inability to protect airway.

What is the most common microbiological etiology of typical community-acquired pneumonia (CAP)?

Streptococcus pneumoniae.

What are the three main atypical bacterial pathogens that cause pneumonia?

Mycoplasma, Chlamydia, and Legionella.

What are the typical pathogens responsible for hospital-acquired pneumonia (HAP)?

Pseudomonas aeruginosa and MRSA.

What are the classic clinical features of Pneumocystis jirovecii (PCP) in HIV patients?

Insidious dyspnea, dry cough, minimal chest exam findings, and exertional desaturation.

What geographic risk factors are associated with Histoplasma and Coccidioides fungal pneumonias?

Histoplasma: Ohio/Mississippi valleys (bat/bird droppings); Coccidioides: Southwest desert.

What does each letter of the CURB-65 pneumonia risk stratification score stand for?

Confusion, Urea (BUN >19), Respiratory rate (>=30), Blood pressure (SBP <90/DBP <=60), Age >=65.

What are the CURB-65 score thresholds and their corresponding action dispositions?

0-1: outpatient; 2: inpatient medical ward; 3 or more: ICU evaluation.

How do typical, atypical, and MRSA/Klebsiella pneumonia differ on chest radiographs?

Typical: lobar consolidation; Atypical/PCP: interstitial/ground-glass infiltrates; MRSA/Klebsiella: cavitary lesions.

Which pneumonia pathogens can be detected using urinary antigen tests?

Legionella and Streptococcus pneumoniae.

What is the empirical antibiotic regimen for outpatient CAP without comorbidities?

Amoxicillin 1 g TID, Doxycycline 100 mg BID, or a Macrolide.

What is the empirical antibiotic regimen for outpatient CAP with comorbidities?

Amoxicillin-clavulanate plus a Macrolide/Doxycycline, or respiratory Fluoroquinolone monotherapy (Levofloxacin).

What is the standard empirical antibiotic treatment for non-ICU inpatient CAP?

Beta-lactam (Ceftriaxone) plus a Macrolide (Azithromycin), or respiratory Fluoroquinolone monotherapy.

What empirical antibiotics are added if MRSA or Pseudomonas is suspected in severe pneumonia?

Add Vancomycin/Linezolid for MRSA; Cefepime or Piperacillin-tazobactam for Pseudomonas.

How is an empyema diagnosed during thoracentesis?

Purulent fluid, positive Gram stain/culture, pH under 7.2, or glucose under 40 mg/dL.

What is the preferred diagnostic test for Influenza, and why?

Molecular assays (RT-PCR) due to significantly higher sensitivity than rapid tests.

What is the standard dose of Oseltamivir (Tamiflu), and when is it most effective?

75 mg PO BID for 5 days; most effective within 48 hours of onset. Initiate treatment regardless of sx duration in patients with severe, complicated or progressive illness or those requiring hospitalization.

What is the clinical sign of secondary bacterial pneumonia ("double sickening") after influenza?

Patient initially improves, then spikes a new fever and develops a productive cough.

What are the classic radiographic features of COVID-19 pneumonitis?

Bilateral, peripheral, basal-predominant ground-glass opacities.

What respiratory management strategy is preferred for isolated hypoxemia in COVID-19?

High-Flow Nasal Cannula (HFNC) and awake self-proning; avoid early intubation.

When is Dexamethasone indicated in COVID-19 pneumonitis, and what is the dose?

When supplemental oxygen is required; dose is 6 mg IV or PO daily.

What is the classic clinical presentation of active pulmonary tuberculosis (TB)?

Cough over 3 weeks, hemoptysis, night sweats, weight loss, and low-grade fever.

What is the immediate, mandatory ED action for a patient with suspected Tuberculosis?

Place the patient in airborne infection isolation (Negative Pressure Room).

What is the diagnostic sputum collection protocol for suspected Tuberculosis?

Three consecutive specimens for AFB smears and NAAT, spaced 8 to 24 hours apart.

What are the three components of Virchow's Triad for venous thromboembolism?

Endothelial injury, stasis, and hypercoagulability.

What are the classic physical examination findings of a Pulmonary Embolism?

Tachypnea, tachycardia, a loud S2 sound, and unilateral calf swelling/warmth.

When is a V/Q scan indicated instead of a CTPA for diagnosing a PE?

Severe renal impairment (GFR <30), severe contrast allergy, or pregnancy with normal CXR.

What bedside echocardiography findings indicate right ventricular strain in a PE?

RV:LV ratio over 1.0, McConnell's sign, or a septal bounce.

How is a submassive Pulmonary Embolism defined?

Hemodynamically stable, but showing right ventricular strain or elevated cardiac biomarkers.

What is the definition and immediate treatment for a massive Pulmonary Embolism?

Sustained hypotension (SBP <90 mmHg for >15 mins); treated with systemic thrombolytics (Alteplase).

What is the primary cause of a Primary Spontaneous Pneumothorax (PSP)?

Rupture of subpleural apical blebs, typically in tall, thin young males.

What is the primary cause of a Secondary Spontaneous Pneumothorax (SSP)?

Complication of preexisting lung disease, most commonly emphysematous bullae in COPD.

Why does a tension pneumothorax lead to obstructive shock and cardiac arrest?

One-way valve air accumulation compresses the vena cava, severely reducing venous return.

What is the critical rule regarding the diagnosis of a tension pneumothorax?

It is a clinical diagnosis; never delay treatment to obtain a chest X-ray.

What pathognomonic ultrasound sign confirms a pneumothorax?

The Lung Point (transition zone where lung sliding disappears).

What is the management for a small, stable primary spontaneous pneumothorax?

Observation and supplemental high-flow 100% oxygen to accelerate air reabsorption.

Where should needle decompression be performed for a tension pneumothorax?

2nd intercostal space midclavicular line or 4th/5th intercostal space anterior axillary line.

What are the anatomical boundaries of the "triangle of safety" for chest tube placement?

Lateral border of pectoralis major, anterior border of latissimus dorsi, and 5th intercostal space.

How do transudative and exudative pleural effusions differ in their pathophysiological drivers?

Transudative: systemic pressure alterations; Exudative: localized inflammation, infection, or malignancy.

What are the three criteria in Light's Criteria used to identify an exudative effusion?

Fluid/serum protein >0.5, fluid/serum LDH >0.6, or fluid LDH >2/3 upper normal serum limit.

What physical exam findings are classic for a pleural effusion?

Stony dullness to percussion, decreased tactile fremitus, and diminished breath sounds.

What is a major contraindication to performing a routine diagnostic thoracentesis?

Effusion clearly caused by known congestive heart failure without atypical features.

What are the diagnostic Berlin Criteria for Acute Respiratory Distress Syndrome (ARDS)?

Acute onset (<1 week), bilateral opacities, non-cardiogenic edema, and PaO2/FiO2 ratio <=300.

What are the PaO2/FiO2 ratio thresholds for mild, moderate, and severe ARDS?

Mild: 201-300; Moderate: 101-200; Severe: 100 or less.

What are the key components of the lung-protective ventilation strategy in ARDS?

Low tidal volumes (6 mL/kg IBW), plateau pressure <30, high PEEP, and permissive hypercapnia.

Why does prone positioning improve ventilation-perfusion matching in severe ARDS?

Relieves heart/abdomen weight from posterior lungs, creating uniform alveolar recruitment.

Define Cor Pulmonale.

Right ventricular hypertrophy, dilation, and failure resulting from chronic pulmonary hypertension.

What is the leading cause of Cor Pulmonale?

Chronic Obstructive Pulmonary Disease (COPD), causing over 50% of cases.

Why must aggressive fluid resuscitation be avoided in patients with Cor Pulmonale?

Volume loading stretches the RV, causing septal shifting, reduced LV filling, and cardiovascular collapse.

How do you calculate the age-adjusted D-dimer cutoff for patients older than 50?

Age x 10 (in micrograms per liter).