Emergancy med exam 2

what should you ask before intubation

• baseline resp status

• smoking hx

• home o2 use

• prior intubation or ICU admission

signs of severe respiratory distress

Unable to speak in full sentences

Retractions, paradoxical respirations

Diaphoresis

Tachypnea > 25 breaths/minute

Audible wheezing or stridor

Signs of imminent respiratory arrest

Decreased mental status

Inability to maintain respiration (poor effort, agonal breathing)

Cyanosis – severe hypoxia

Silent chest

what is the path of o2

Upper airway

Lower airway

Lungs

Alveoli

Blood

Blood vessels

Heart

Chest wall

what are can’t miss diagnosis for dyspnea

Upper airway obstruction: foreign body, angioedema, hemorrhage

Tension pneumothorax

Pulmonary embolism

Neuromuscular weakness: Guillain-Barré syndrome, myasthenia gravis

Fat embolism (e.g., long bone fracture, orthopedic trauma)

what are the red flags for asthma

• prior instubation/ ICU addmision

• frequent ED visits

• more than 2 hostpitlizations in the past year

• SABA overdose

• poor ICd adherence

• recent steriod use

this increase the risk of death

red flag sx in acute asthma

• silent chest

• unable to speak in full sentances

• altered mental status

• cyanosis

• 02 less than 90%

when to get cxr for asthma

• poor response to therapy

• admission

• suspected pneumina

• pneumothorax

• pneumomediastnum

what are the tx for asthma (steps 7)

1. o2 titrate to 93/95%

2. SABA albuterol is MDI+spacer (4-8 puffs q20 min) use continous nebulization for severe sxacerbation

3. PO steriods (within an hour)

4. IPRATROPIUM (SAMA) if not responding

5. magnesium sulfate IV

6. noninvasive postive pressure ventilation BiPAP

7. mechanical ventilation

when to use mechanical ventilation in asthma

◦Progressive respiratory fatigue

◦Worsening hypercapnia/acidosis

◦Altered mental status

◦Inability to maintain oxygenation/ventilation

why do you want to aviod tubing asthma pt

can cause : air trapping, barotrauma (pneumothorax), hypotension- but do not delay iintubation with respiratory failure

when to admt asthma

Incomplete or poor response to ED treatment

Persistent respiratory distress or hypoxemia

PEF < 40% of predicted

Prior severe asthma / high-risk features

Significant comorbidities

what to send asthma pt home with

Continue ICS-containing therapy

Short course systemic corticosteroid when indicated (prednisone 40-50 mg/day x 5-7 days)

Rescue inhaler + spacer + technique review

Asthma action plan + close follow-up

triad for COPD

• dyspnea

• cough

• sputum volume and purulence

steriods in copod

be careful and use the lowest dose required

what can mimick copd

• pneumonia

• CHF

• pneumothorax

• PE

• ACS

COPD exacerbation tx

• O2 88-92%

• SABA+SAMA

• steriod

• abx

• BiPAP

• 
  

when to gibe abx in copd

• increase sputum or rquire ventilation

what abx to use in copd

• augmentin

• azithro

• doxy

what are the indication for BiPAP in COPD exacerbation

opH < 7.35 and/or PaCO₂ > 45 mmHg

oPaO₂ < 60 mm Hg or SpO₂ < 90%

oSevere dyspnea with respiratory fatigue

indications for tubing copd exacerbation

Failure of NIPPV (intolerance, worsening acidosis/gas exchange)

Severe altered mental status

Respiratory or cardiac arrest

Unable to protect airway

Hemodynamic instability

COPD ICU

NIV requirement or need for mechanical ventilation

Hemodynamic instability

Worsening acidosis or mental status

COPD admission

Inadequate response to ED treatment or persistent severe dyspnea

New/increased oxygen requirement

Hypercapnia with acidosis

Significant comorbidities (e.g., CHF, arrhythmias, diabetes)

Poor home support / unreliable follow-up

when to discharge COPD

Symptoms substantially improved with stable oxygenation

Able to ambulate/manage ADLs

Medications available

Reliable follow up with clear discharge plan

rust-colored sputum, single episode of rigors

Streptococcus pneumoniae

COPD, smoking

Haemophilus influenzae

post-influenza pneumonia, lung abscess, empyema

Staphylococcus aureus

currant jelly sputum, bulging fissure, alcoholics, diabetics

Klebsiella pneumoniae

walking pneumonia”, young adults, bullous myringitis

Mycoplasma pneumoniae

pharyngitis/laryngitis, staccato cough, affects young adults/infants

Chlamydia pneumoniae

pneumonia + GI symptoms, contaminated water supply/AC system, hyponatremia

Legionella

curb score of 1

low rsk of death

curb score of 2

mod risk

curb score of 3-5

high severity

when can pneumonia be outpatent

Hemodynamically stable

No significant hypoxemia

Able to take PO medications

No unstable comorbidities

Reliable follow-up/home support

Low-risk PSI/CURB-65 supports discharge

when to admit for pneumonia

Hypoxemia or need for supplemental O₂

Hemodynamic instability

Significant comorbidities

Unable to tolerate PO

Altered mental status

Higher-risk PSI/CURB-65

Unsafe outpatient situation

When does pneumoniaa go to ICU

Respiratory failure requiring mechanical ventilation

Septic shock requiring vasopressors

Severe CAP features / rapidly worsening respiratory failure

ed abx tx for pneumonia

Outpatient CAP

Healthy, no major comorbidities

•Amoxicillin or Doxycycline

Comorbidities (heart/lung/renal/liver disease, diabetes, alcoholism, malignancy)

•Amoxicillin-clavulanate (typical) + azithromycin/doxycycline (atypical) or respiratory fluoroquinolone (typical + atypical)

Hospitalized – Non-severe CAP

•Ceftriaxone (typical)  + azithromycin (atypical)  

•OR monotherapy with Levofloxacin or Moxifloxacin IV

Inpatient - Severe CAP

•Ceftriaxone + azithromycin

•OR ceftriaxone + respiratory fluoroquinolone

•Add MRSA (Vancomycin or linezolid) or Pseudomonas (piperacillin-tazobactam) coverage only if risk factors

bronchitis

can last 2-3 wks and be purulent but is viral cause and does not need abx but shoudnt have fever, rr above 24, hr above 100, focal lung findings but beside that just supportive care.

what can you use if someone with bronchitis is wheezing or having bronchospasms

albuetrol

what are risk risk influenza groups

over 65 years of age and less than 5 yrs, if your preganant, chronic cardiopulmonary diseae, immunocomprimised

wht is the antiviral used for influenza

oseltamivir bested used if less than 48 hours

what are secondary complications for influenza

• secondry bacterial pneumonia

• exacerbation of asthma/ COPD

what are the antivirial used for COVID

• nirmatrelvir/ ritonavir if 5 days or less

• remdesivir IV if 7 days or less

• molnupirvir alternative if no other option

covid 19 addmision

• less than 94 %

• hemodynamic instability

• rapid clinical deterioration

when to think TB

prolonged cough, fever/night, sweat and weight loss

how do three different TB differ on chest x ray

• primary: infiltrate hilar adenopathy

• reactivations: upper lobe cavitary disease

• millary- diffused tiny nodules

TST/IGRA detect TB infection, but do not distinguish

latent from active TB (tool to determine pt risk of having TB)

if active pulmonary TB suspect

•Sputum AFB smear

•NAAT

•Mycobacterial culture

if you suspect TB you hsould automatically

resiratory isolation and protection for staff is suspected … •N95 respirator for healthcare personnel

Notify infection control/public health as appropriate

inital TB tx

Rifampin

Isoniazid

Pyrazinamide

Ethambutol

what is acute respiratory distress

•Acute hypoxemic respiratory failure

•Diffuse inflammatory lung injury → ↑ alveolar-capillary permeability

Noncardiogenic pulmonary edema

secondary to an illness

ARDS managment

mechanical ventilation but treating the underlaying cause

what is the cause of a pnuemothorax

• air in the pleural space causes loss of the negative intrapleural pressure causing a collapse

tension px

decrease venous return, obstruction shock, and immediate life threatening emergency

PE for tension pneumo

•Severe respiratory distress

•Hypotension, JVD, obstructive shock

•Unilateral absent breath sounds

•Tracheal deviation is a late finding

•May rapidly progress to cardiovascular collapse

critically ill patient develops acute, refractory hypoxemia + bilateral pulmonary opacities without cardiogenic pulmonary edema.

ARDS

in all pt with sudden pleurtic chest pain and dyspnea

think tension pneumo

primary spontanous managment

stable, minimally symptomatic (regardless of size)

•Observe 3-6 h, analgesia, supplemental O₂ if hypoxemic (SpO₂ < 92%)

•Repeat CXR -> discharge if stable (RR<24, HR>60 and <120, normal BP, SpO₂>90%, speaking in full sentences)

•Early outpatient follow-up

Reserve intervention for symptomatic progression or clinical instability

what managment for primary peunmothorax when managment is needed

•Needle aspiration first-line (16-G catheter, 2nd intercostal space (ICS) midclavicular line)

•If aspiration fails → small-bore (≤14-Fr) chest tube

•Observe/admit as appropriate

managment for secondary ptx

•Supplemental oxygen, chest tube, admit all SSP patients

•Thoracic surgery consult

•High recurrence risk -> may need pleurodesis

tension pneumothorax managment

•Immediate large bore (14 G) needle decompression 5th ICS anterior axillary line or 2^nd ICS midclavicular line

•Follow with chest tube placement and admission

what ICS for each pneumothorax intervention

hemoptysis what is and how to tell clinical impact

bright red frothy associated with cough and be a bleed in upper airway or GI and measured blood volume for clinical impact

how do pt die in hemoptysis

asphyxiation rather than blood loss

need to do rest of this pp

the rest is GI emergancy but skpped the first 10ish slides

what are the common causes of hemoptysis

infection, malgignacy, bronchietcstasis, TB, and PE

what tool can be used in hemoptysis to localize bleeding any may provide treatment

bronchoscopy

how to treat life threating hemoptysis

•ABCs; supplemental O₂

•Secure airway if threatened

•Large-bore IV access; type & cross

•Correct coagulopathy when appropriate

•Known bleeding side → bleeding lung DOWN

•Early pulmonology + interventional radiology

•Bronchoscopy and/or bronchial artery embolization

•ICU admission

cause of appendicitis

luminal obstrcucton usually fecalith

physical exam for appendcts

• McBurnery - single most important sign

• rosving

• psoas

• obturator

what are the 3 most predicitve factor for acute appendicitis

• RLQ pain

• abdominal rigidiity

• migrating pain from periumbilical RLQ

rosving

palpating LLQ cause pain in rlq

psoas sign

pain when pt tries to flex hip againt resistance or is on there side they have pain with passive hip extention

orbturator sign

flexion of the knee and internal hip rotation

what lab would be elevated in appendicitis

• mild leukocytosis with L shift

• CRP and WBC

but normal wbc does does r/o

imaging for appendicitis

cr abdomen with IV contrast

what will appendicits show on ct with iv contrast

• enlarged appendix above 6mm, wall thickening

• periappendiceal stranding

• apppendilcolith or abcess

imaging for appendicitis in kid or pregenancy

ultrasound first

what will ultrasounf of appendix show for acute appendicitis

noncompressible appendix with diamter greater than 6

what is the ED tx for appendicitis

NPO

IV fluids

Analgesia (opioids)

Antiemetics

IV broad-spectrum antibiotics (ampicillin/sulbactam or piperacillin/tazobactam

cholelithiasis

aka biliary colic

is when there are gallstones in gallbladder that intermittently obstruct the gallbladder neck - no inflammation

cholangitis

inflammation of the bile duct caused by bacterial infection (often tigger by stone)

acte cholecystitis

gallstone that block the cystic duct and the obstruction causes inflammation

choledocholithiasis

stone obstruction in the commone bile duct and means the bile can not drain into the duosenum

colic pain that radiated to r shoulder

cholelithiasis

clay colored stools, tea color urin or jaundice

choledocholithiasis

epigastric pain longer than 6 hrs with N/V

acute cholecystitis

charcot triad

fever

RUQ PAIN

juandice

cholangitis

reynold pentad

fever

ruq pain

juandice

confusion

hypotention

cholangitis

slide 28

what is the imaging for biliary tree

ultrasound first line and then get CT abdomen/pelvis with IV contrast

Biliary colic (Symptomatic cholelithiasis) tx

Symptomatic treatment: IV fluids, analgesics (NSAIDs first-line), antiemetics

Discharge if symptoms resolve; Return precautions: pain > 6 hours, fever, or jaundice

Outpatient general surgery referral → elective laparoscopic cholecystectomy

Acute cholecystitis tx

IV fluids, analgesics, antiemetics

IV antibiotics: ampicillin-sulbactam OR piperacillin-tazobactam

Admit -> early laparoscopic cholecystectomy (within 24–72 hours)

Choledocholithiasis

IV fluids, analgesics, antiemetics

IV antibiotics: ampicillin-sulbactam OR piperacillin-tazobactam

Admit -> early laparoscopic cholecystectomy (within 24–72 hours)

Acute cholangitis

Aggressive IV fluids + broad-spectrum IV antibiotics (piperacillin-tazobactam)

Admit for urgent ERCP for biliary decompression

what biliary disease is a medical emergancy

Aggressive IV fluids + broad-spectrum IV antibiotics (piperacillin-tazobactam)

Admit for urgent ERCP for biliary decompression

mc cause of pancreatitis

gallstones

what kind of pain for pancreatitis

Acute, severe, constant epigastric pain — deep and penetrating

Radiates to back; also chest, flanks

Worsened by eating, drinking, or lying supine

Relieved by sitting up and leaning forward

Associated N/V, anorexia

what are signs of serve pancreatitis

Cullen sign – periumbilical ecchymosis (retroperitoneal hemorrhage tracking to umbilicus)

Grey Turner sign –flank ecchymosis (retroperitoneal hemorrhage)