1. Research humor

2. Inservice review
THORACIC

3. Pitbull? No problem!

4. Asthma Risk factors for sudden death History of severe exacerbations
Use of greater than 2 canisters of albuterol per month
Prior intubation
Current use of oral steroids or recent withdrawal from oral steroids
Prior ICU admit
Comorbid illness such as COPD or cardiovascular disease
Greater or equal to 2 hospitalizations in the past year
Illicit drug use
Greater or equal to 3 ED visits in the past year
Psychiatric disease
Hospitalization or ED visit in the last month
Low socioeconomic status
Poor perception of airflow obstruction or its severity

5. Asthma Rarely need ABG. New onset will need chest x-ray. Treatment:
Acute versus chronic.
More than two episodes a week, start low dose inhaled corticosteroids.
Daily symptoms require long-acting inhaled beta-2 agonist, in addition to corticosteroids.
Leukotriene modifiers, cromolyn, and theophylline are considered second or third line agents.

6. stage
symptoms
PEFor FEV1
daily treatment
Mild intermittent
Greater than two episodes per week, during the day or greater than two episodes at night a month
Greater than 80%
No daily treatment
Mild persistent
Less than one episode per day or greater than two episodes per month at night
Low dose inhaled corticosteroids may use additional third line treatment
Moderate persistent
Daily or more than one nightly episode per week
60 to 80%
Low to medium dose inhaled corticosteroids plus long-acting beta-2 agonist may at third line treatment
Severe persistent
Continual during the day frequent at night
Less than 60%
High-dose inhaled corticosteroid plus long-acting beta-2 agonist oral corticosteroids is needed

7. Asthma Intubation for respiratory collapse.
Ventilator setting should be set for a prolonged expiratory times.
Admission= FEV1 or peak flow ≤ 50% of predicted after three hours of therapy.
May be discharged = FEV1 or peak flows ≥ 70% of predicted. Stable for 30 minutes after last treatment.

8. Asthma
At discharge patients should have refill of beta-2 agonists and 3 to 10 days of oral corticosteroids. Plus or minus inhaled corticosteroids.

9. Asthma Initial management:
02 to keep sats greater than or equal to 92%.
Inhaled beta-2 agonists.
Anti-cholinergics (ipratropium)
Systemic corticosteroids, if no immediate response

11. Acute bronchitis Acute means it has lasted < three weeks.
90% of bronchitis is viral, influenza A or B, Para-influenza, RSV, rhino virus, coronavirus, or metapneumonia virus.
Mycoplasma, Chlamydia and pertussis are becoming more common causes.

12. Acute bronchitis Fever suggests influenza.
Severe paroxysmal cough with post—tussive vomiting suggests pertussis.
Diagnosis is clinical.
If you think it may be pneumonia, cxr.
Treatment: guaifenesin is useful to mobilize secretions, antitussives can be used for reduction of symptoms.

13. Chronic bronchitis
Presence of cough and sputum production on most days over at least a three-month period for more than two consecutive years in a patient without other explanations for cough. *Almost all are smokers.
Treatment includes smoking cessation.

15. croup
Obstruction of upper airway due to infection. Spasmodic croup is noninfectious. Parainfluenza one is the most common cause. RSV, flu, adenovirus are other causes.
‘steeple sign’
Six to 36 months. Barking cough hoarseness inspiratory stridor. May have hypoxia, cyanosis and severe distress.
Treatment is inhaled mist, corticosteroids, inhaled epinephrine in severe cases.
epiglotitis
Cellulitis of epiglottis, HIB .
‘Thumb sign’
Sniffing position, stridor and drooling are signs of impending respiratory obstruction. Visualization of airway in adults
Kid stuff

16. bronciolitis
Nonspecific inflammatory disorder. Variety of causes.
Peak 2-6 months: fever, wheezing, chest retractions and tachypnea. Tiny tots may have apnea. Clinical diagnosis. Steroids are of no benefit. Treatment includes warm humidified oxygen, racemic epinephrine. Admit if toxic appearance. Obvious evidence of respiratory distress, pneumonia, or poor social circumstances.
pertusis
‘whooping cough’, small gram-negative coccobacillus. Three stages: catarrhal stage, paroxysmal stage can last for months, convalescent stage can last for months.
Adults often misdiagnosed with bronchitis.
Clinical diagnosis cough for two weeks, inspiratory whoop, post -tussive vomiting, exposure or outbreak.

17. COPD Emphysema – pink puffer Alveolar wall destruction
Chronic bronchitis – blue bloater
Alveolar wall destruction
Mostly caused by smoking
(a– 1antitrypsin deficiency)
Less CO2 retention and hypoxemia than blue bloaters
Better prognosis than blue bloater
Chronic cough
Mostly caused by smoking
Signs of right sided heart failure
Most die in2-4 years
Oxygen treatment

18. COPD
FEV1 drops below 50% of predicted, exertional dyspnea and cough, minor hemoptysis, tachypnea and pulsus paradoxus.
Clubbing of fingers, barrel chest, and pursed lip exhalation.
ABG’s are helpful with exacerbations.
Chest x-rays are necessary.

19. COPD

20. Acute COPD
ABG
All ill pts, PaO2<50mmHg, PaCO2>70mmHg, Ph<7.3= life threatening
CXR
r/o pneumonia or pneumothorax
EKG
R heart hypertropy, consider PE, CHF, MI O2
Monitor for worsening hypercapnia
Beta 2 agonist
First line is albuterol
anticholenergic
Ipratropium if not responding to albuterol
methylxanthines
Contriversial, side effects: vomiting, arrhythmias, hypotension, and sz
corticosteroids
Oral = iv
antibiotics
Fever or purulent sputum, cover S. pneumonae, H influenza, M catarrhalis

21. Red neck pet carrier

22. Angioedema ACE inhibitor induced angioedema
Creates angioedema by blocking the conversion of bradykinin and substance P to inactive metabolites.
60% within one week of starting med, but has been known to occur at any time during treatment.
Less than 1% of those treated with ACE–I have angioedema.
No urticaria, not related to ACE cough.

23. Angioedema ACE inhibitor induced angioedema
Treatment is airway management and stopping offending medication. Steroids and antihistamines may not work due to pathophys ; epinephrine should be tried but, may not work.
*FFP is effective and naloxone can be used for hypotension.

24. Angioedema
Several other causes; the one on the test will probably be C1-esterase inhibitor.
FFP has C1-INH in it.

25. Anaphylaxis
The first and most important therapy in anaphylaxis is epinephrine. There are no absolute contraindications to epinephrine in the setting of anaphylaxis.
Airway: Immediate intubation if evidence of impending airway obstruction from angioedema.
IM Epinephrine: 0.3 to 0.5 mL of the 1:1,000, preferably in the anterior or lateral thigh; can repeat every 3 to 5 minutes as needed.
Treat hypotension with rapid infusion of 1-2 liters IV.

26. Anaphylaxis
IV Epinephrine: put 0.1 mL of 1:1,000 dilution into 10 cc of normal saline, give 1-2 mL per minute, titrated to response
Oxygen: give 100 percent oxygen
Albuterol: Treat bronchospasm with mg in 3 mL saline via nebulizer

27. Anaphylaxis
Antihistamine (H1 blocker): Give all patients diphenhydramine mg IV; can give IM if symptoms are less severe
Antihistamine (H2 blocker): Give all patients ranitidine (zantac) 50 mg IV or famotidine (pepcid)20 mg IV
Corticosteroid: Consider giving methylprednisolone 125 mg IV or dexamethaone 20 mg IV

28. SAGINAW

29. Pulmonary embolism
No single clinical finding is sensitive or specific for PE.
PIOPED= 97% have either dyspnea, tachypnea or chest pain.
The most common symptoms: dyspnea (73 percent), pleuritic pain (66 percent), cough (37 percent) and hemoptysis (13 percent).
The most common signs : tachypnea (70 percent), rales (51 percent), tachycardia (30 percent), a fourth heart sound (24 percent).
Fever, usually with a temperature <102ºF (38.9ºC), occurred in 14 percent of patients with pulmonary embolism and no other apparent source for an elevated temperature .

30. Pulmonary embolism
In patients with massive PE, these physical findings may be accompanied by acute right ventricular failure, manifested by increased jugular venous pressure, a right-sided S3, and a parasternal lift.
Most do not have leg sx.
Hampton hump on xray, Westermark sign
Saddle embolism on CT
S1Q3T3

31. Pulmonary embolism

32. Pulmonary embolism
Westermark sign – vasoconstriction seen distal to a pulmonary embolus (PE).
While the chest x-ray is abnormal in the majority of PE cases, the Westermark sign is seen in only 2% of patients.

33. Pulmonary embolism

34. Pulmonary embolism– ‘Classic findings’T3 Q3

35. Pulmonary embolism– ‘Classic findings’
S1Q3T3 are neither pathognomonic, sensitive or specific S1 T3 Q3

36. Pulmonary embolism What an EKG is more likely to show in PE:
***most common is non specific ST segment and T wave abnormalities***
Might see:
Right heart strain – RBBB
T wave inversion in V1-V4

37. Pulmonary embolism

38. Pulmonary Embolism – risk factors
Immobilization, surgery within the last three months, stroke, history of venous thromboembolism, malignancy, preexisting respiratory disease, chronic heart disease.
Additional risk factors identified in women include : Obesity, Heavy cigarette smoking, Hypertension

39. Pulmonary Embolism
Mortality without treatment is 30%, with treatment is 2-8%
Treatment : heparin or
Enoxaparin: 1 mg/kg per dose administered subcutaneously twice daily. Alternatively, 1.5 mg/kg administered subcutaneously once daily. (Marty told us that on Tuesday!)
Trans to Coumadin.

40. Pulmonary Embolism IVC for those who can’t have anticoags.
Thrombolytics no mortality benefit over heparin but is recommended in unstable patients.
Embolectomy for those with contraindications to thrombolytics.

42. Thoracic
Costrochondritis – diffuse inflammation of costrochondral and costrosternal joints
Tender but no swelling or reddness
Women over 40 and associated with fibromyalgia
Non steroidals, muscle relaxants, antidepressants, PT
Self limiting

43. Thoracic Cystic fibrosis – autosomal recessive
Chronic cough
Recurrent pulmonary infections
Pancreatic insufficiency
Chloride transporter in exocrine glands, thick mucous and difficulty clearing.

44. Thoracic
Cystic fibrosis – chronic cough, pneumonias (P. aeruginosa, S. aureus, H. influenza,) persistant changes on CXR, airway abnormality, clubbing, sinusitis, nasal polyps.
Non respiratory - meconium ileus, distal gi obst., pancreatic insufficiency, biliary cirrhosis, failure to thrive, male infertility, osteoporosis.

45. Thoracic
Cystic fibrosis – 7% diagnosed as adults. 50% in the first 6 mo.
Dx’d with sweat chloride test.
Tx – appropriate abx.
Tobramycin covers pseudamonas (plus)
Ticarcillin, piperacillin (or)
Ceftazidime, cefepime (or)
imipenem/cilastatin, meropenem
b agonist helpful for bronchospasm.
Always double coverage

46. Thoracic Pleural effusion –most common causes: CHF, pneumonia, CA, PE
Short of breath, dullness to percussion, decreased breath sounds
150ml to blunt costrophrenic angle
Lights criteria: protein ratio greater than 0.5, LDH ratio greater than 0.6, LDH greater than two thirds the upper limits of the laboratory's normal serum LDH

47. Thoracic
Chronic medistinitis is diffuse fibrosis of the soft tissues of the mediastinum. This is sometimes the consequence of histoplasmosis, tuberculosis or radiation therapy.
Causes constriction and superior vena cava syndrome or pulmonary edema from compression of pulmonary veins.
Treatment = steroids or surgical decompression of affected vessels.

48. Thoracic
Acute mediastinitis Causes: cardiovascular surgery, perforation of the esophagus or from contiguous spread of odontogenic or retropharyngeal infections.
Most cases of result from complications of cardiovascular or endoscopic surgical procedures.
Treatment usually involves aggressive intravenous antibiotic therapy and hydration. Abscesses will need surgical drainage.

49. Thoracic Pneumomediastinum causes:
Boerhaave syndrome- full thickness tear of the esophagus. (what is the name of an intimal tear of the esphagus?)
What causes Boerhaaves’?
What is the cause of non-Boerhaaves’ full thickness tear? (85-90% of full thickness tears?)
Abx, surgical repair, iv hydration, npo
iatrogenic

50. Thoracic
Clinical presentation, epigastric chest or back pain after vomiting. May present in shock or sepsis.
Distal tears worse than proximal. most common, left posterolateral wall of the lower third of the esophagus, 2-3 cm before the stomach.
You will see mediastial air on chest XR.
You may hear Hammond crunch, air which has tracted to the pericardium on auscultation.
Diagnosis and treatment for Boerhaaves? water soluble contrast ct, tx broad spectrum abx, tx shock, npo, iv fluids
Dx –

51. Thoracic Other leading cause of pneumomediastinum?
Herman Boerhaave ( )
asthma

52. Thoracic Other leading cause of pneumomediastinum? ASTHMA
Herman Boerhaave ( )
asthma

53. Thoracic Meanwhile, back at…
Mallory-Weiss syndrome, may present with violent vomiting/retching with hematemisis Or
Just melena; without h/o violent vomiting/retching.
Associated with alcoholism and eating disorders.

54. Thoracic Diagnosed with scope, not mediastinal air on CXR.
Bleeding usually stops on its own, or if the pt is sick enough and doesn’t have any coagulants and comes in late and the bleeding can’t be stopped…

56. Thoracic
Esophageal FB vs Tracheal FB

58. Thoracic Inhalation injury – main cause of death in burn patients.
Steam inhalation burns may happen past the vocal cords.
Clinical presentation – SOB, carbonaceous sputum, singed nasal hair, hoarseness and wheeze.
Primary CXR may not show pulmonary edema.
Bronchoscopy may be needed to show extent of injuries.
Tx – humidified O2 intubate as necessary…

59. Thoracic What is ‘necessary’?
Carbonaceous sputum, hoarse voice, full thickness face or perioral burns, circumferential neck burns, altered mental status (the patients, not yours), hypoxia, supraglottic edema.
Ask yourself ‘if I don’t tube now, will I be able to later?’ or ‘what is going to be the progress of this patient?’

61. Thoracic Environmental lung disease - pneumoconiosis
Asbestosis
Silicosis
Coal workers pneumoconiosis
Exposure to coal dust, asbestos, talc, aluminum powder.
Fibrotic lung disease presents with restrictive lung disease and fine crackles.
No specific tx. Should have vaccines, stop smoking and home O2 if necessary.
Buddy Ebsen
Buddy ebsen, jack haley jr
Jack Haley

62. Thoracic Environmental lung disease - pneumoconiosis.
CXR will show nodular infiltrates and plaques.

64. Questions Which of the following is an appropriate treatment of croup?
A. Beta-agonist
B. anticholinergics
C. heliox
D. inhaled epinephrine

65. Questions Which of the following is an appropriate treatment of croup?
A. Beta-agonist
B. anticholinergics
C. heliox
D. inhaled epinephrine

66. Questions
Which of the following has not been shown to benefit in the treatment of croup?
A. inhaled mist
B. corticosteroids
C. inhaled epinephrine

67. Questions
Which of the following has not been shown to benefit in the treatment of croup?
A. inhaled mist
B. corticosteroids
C. inhaled epinephrine

69. Questions
Which of the following does not describe peritonsillar abcess?
A. unilateral mass visualized on visual exam
B. cough
C. shaggy trachea on x-ray
D. painful swallowing

70. Questions
Which of the following does not describe peritonsillar abcess?
A. unilateral mass visualized on visual exam
B. cough
C. shaggy trachea on x-ray
D. painful swallowing

71. Questions Diagnosis of adult epiglottitis is made by:
A. clinical presentation of sore throat with no significant pharyngitis
B. CT of neck
C. soft tissue xray showing ‘steeple sign’
D. direct visualization of swollen epiglottis by laryngoscopy
Lateral soft tissue will show ‘thumb sign’

72. Questions Diagnosis of adult epiglottitis is made by:
A. clinical presentation of sore throat with no significant pharyngitis
B. CT of neck
C. soft tissue xray showing ‘steeple sign’
D. direct visualization of swollen epiglottis by laryngoscopy

73. Questions
What percentage of adult patients with epiglottitis are initially misdiagnosed:
A. 10%
B. 25%
C. 33%
D. 50%

74. Questions
What percentage of adult patients with epiglottitis are initially misdiagnosed:
A. 10%
B. 25%
C. 33%
D. 50%
Often diagnosed with strep throat

75. Questions
Pts with mild epiglottitis should be_______, with severe epiglottitis _________.
A. discharged with oral antibiotics, admitted.
B. discharged with oral antibiotics, admitted to ICU.
C. admit with IV antibiotics, admit to ICU with antibiotics.
D. admit to ICU with antibiotics, intubated with antibiotics

76. Questions
Pts with mild epiglottitis should be_______, with severe epiglottitis _________.
A. discharged with oral antibiotics, admitted.
B. discharged with oral antibiotics, admitted to ICU.
C. admit with IV antibiotics, admit to ICU with antibiotics.
D. admit to ICU with antibiotics, intubated with antibiotics

78. Questions An adult with pertussis will:
A. rarely have ‘whoop’ with cough
B. often be misdignosed with bronchitis
C. have prolonged paroxysmal phase
D. have been previous immunization
E. have all of the above

79. Questions An adult with pertussis will:
A. rarely have ‘whoop’ with cough
B. often be misdignosed with bronchitis
C. have prolonged paroxysmal phase
D. have been previous immunization
E. have all of the above

80. Questions Pertussis is best diagnosed: A. clinically
B. by culture of aspiration of nasopharyngeal secretions.
C. by cough, leukocytosis of 50K with lymphocytosis predominance and CXR
D. none of the above

81. Questions Pertussis is best diagnosed: A. clinically
B. by culture of aspiration of nasopharyngeal secretions.
C. by cough, leukocytosis of 50K with lymphocytosis predominance and CXR
D. none of the above

82. Questions Pertussis treatment: (2 answers)
A. helps prevent transmission
B. azithromycin or clarithromycin
C. should never include erythromycin due to GI side effects and QT prolongation
D. close contacts are not treated

83. Questions Pertussis treatment: A. helps prevent transmission
B. azithromycin or clarithromycin
C. should never include erythromycin due to GI side effects and QT prolongation
D. close contacts are not treated

84. Questions What age group is represents the majority of FB aspirations?
A mo
B. 1 – 3 yr
C. 5 – 7 yr
D yr

85. Questions What age group is represents the majority of FB aspirations?
A mo
B. 1 – 3 yr
C. 5 – 7 yr
D yr

86. Questions What % of CXR’s will be normal in aspirated FB’s? A. 10%

87. Questions What % of CXR’s will be normal in aspirated FB’s? A. 10%

88. Questions What is the most common aspirated object in children? A. Gum
B. Nuts
C. Coins
D. Batteries
E. Pen caps

89. Questions What is the most common aspirated object in children? A. Gum
B. Nuts
C. Coins
D. Batteries
E. Pen caps

90. Questions
Diffuse alveolar damage with inflammation and accumulation of proteinaceous fluid in the alveoli is called:
A. pneumonia
B. bronchospamoplasticdysplacia
C. Acute lung injury/acute respiratory distress syndrome
D. Reactive airway disease/COPD

91. Questions
Diffuse alveolar damage with inflammation and accumulation of proteinaceous fluid in the alveoli is called:
A. pneumonia
B. bronchospamoplasticdysplacia
C. Acute lung injury/acute respiratory distress syndrome
D. Reactive airway disease/COPD

92. Questions ARDS presents with: Dyspnea, tachypnea, rales
peripheral edema, jugular distension and S3 gallop
Fever, cough, vomiting
Cough with thick yellow mucous

93. Questions ARDS presents with: Dyspnea, tachypnea, rales
peripheral edema, jugular distension and S3 gallop
Fever, cough, vomiting
Cough with thick yellow mucous

94. Questions Signs of ARDS include: A. Rhonci B. Rales C. Hammond crunch
D. Crackles

95. Questions Signs of ARDS include: A. Rhonci B. Rales C. Hammond crunch
D. Crackles

96. Questions Treatment for ARDS may include: A. Intubate
B. Treat underlying cause
C. Permissive hypercapnia
D. Ventilate with low tidal volumes and reduced pressures
E. Diuretics
F. All of the above except one

97. Questions Treatment for ARDS may include: A. Intubate
B. Treat underlying cause
C. Permissive hypercapnia
D. Ventilate with low tidal volumes and reduced pressures
E. Diuretics
F. All of the above except one

99. END Trauma
…tune in next time for another exciting episode of lightning in-service review…

100. END