Respiratory
Describe the pediatric assessment triangle
Appearance - (TICLS) Tone, interactiveness, consolability, look/gaze, speech/cry
Work of breathing- abnormal airway sounds (snoring, hoarse, stridor, grunting, wheezing), abnormal posture (sniffing/tripod), Retractions, flaring (nares)
Circulation to skin- pallor (poor perfusion, anemia, hypoxia), mottling, cyanosis (poor perfusion/poor oxygenation)
Bronchiolitis - most common organism
Respiratory Syncytial Virus (RSV) most common cause
A 19-year-old female ingested an unknown quantity of Elavil and Ativan approximately 3 hours ago. She is slow to answer your questions and her speech is slurred. Her BP is 80/60 mm Hg, her pulse is 150 beats/min, and her respirations are 22 breaths/min. The ECG reveals sinus tachycardia with QRS complexes that measure 0.08 seconds. Treatment should include:
A) 1 mEq/kg of sodium bicarbonate.
B) sequential 20 mL/kg IV fluid boluses.
C) 1 to 2 g/kg of activated charcoal.
D) 0.4 to 2 mg of naloxone slow IV push.
B) sequential 20 mL/kg IV fluid boluses.
A 60-year-old female presents with confusion, shortness of breath, and diaphoresis. Her blood pressure is 70/40 mm Hg and her heart rate is 40 beats/min. The cardiac monitor reveals a slow, wide complex rhythm with dissociated P waves. After applying supplemental oxygen, you should:
A) give her up to 325 mg of baby aspirin.
B) start an IV and give 0.5 mg of atropine.
C) start an IV and give a rapid fluid bolus.
D) begin immediate transcutaneous pacing.
D) begin immediate transcutaneous pacing.
Shortly after his dialysis treatment, a 66-year-old man presents with confusion, a headache, and nausea. You should suspect:
A) interstitial nephritis.
B) acute air embolism.
C) severe hyperkalemia.
D) disequilibrium syndrome.
D) disequilibrium syndrome
Dialysis rapidly lowers the concentration of urea in the blood, whereas the concentration of solutes in the cerebrospinal fluid (CSF) remains high. Water moves by osmosis from a solution of lower concentration into a solution of higher concentration. Thus, as a consequence of dialysis, water initially shifts from the bloodstream into the CSF, which mildly increases intracranial pressure. If this occurs, the patient may experience disequilibrium syndrome, a condition characterized by nausea, vomiting, headache, and confusion.
The definition for chronic bronchitis
Sputum production most days of the month for 3 or more months out of the year for more than 2 years
The chronic dysfunction of the endocrine system that targets multiple body systems, primarily respiratory and digestive systems. Caused by a defective gene- makes chloride difficult to move through cells. (which disease)
Cystic Fibrosis
Which drug OD will result in the following- shock, cardiac arrest and bowel ischemia- decrease HR and BP, altered LOC, seizures
1. Hydromorph
2. Carvedilol
3. Luminal
4. Verapamil
4. Verapamil - only one that causes bowel ischemia (Calcium channel blockers)
During resuscitation of a 60-year-old man with ventricular fibrillation, you restore spontaneous circulation following CPR, defibrillation, two doses of epinephrine, and one dose of amiodarone. The patient remains unresponsive and apneic. Which of the following represents the MOST appropriate post-arrest care for this patient?
A) Ventilate at a rate of 10 to 12 breaths/min, support blood pressure, and obtain a 12-lead ECG.
B) Hyperventilate the patient, administer a normal saline bolus, and begin an amiodarone infusion at 0.5 mg/min.
C) Ventilate at a rate of 10 breaths/min, support blood pressure, and give 150 mg of amiodarone over 10 minutes.
D) Ventilate at a rate of 20 breaths/min, begin an epinephrine infusion to maintain perfusion, and keep the patient warm.
A) Ventilate at a rate of 10 to 12 breaths/min, support blood pressure, and obtain a 12-lead ECG.
You are attempting to resuscitate a 50-year-old man in cardiac arrest. The patient has a history of congestive heart failure, hypertension, and cirrhosis of the liver. The cardiac monitor reveals a slow, wide complex rhythm. CPR is ongoing and the patient has been intubated. In addition to looking for potentially reversible causes of the patient's condition, further treatment should include:
A) hyperventilation for presumed acidosis and 1 mg of epinephrine 1:10,000 every 3 to 5 minutes.
B) one breath every 3 to 5 seconds, a 2-liter normal saline bolus, a vasopressor, and a dopamine infusion.
C) ventilations at a rate of 10 breaths/min and 1 mg of epinephrine 1:10,000 every 3 to 5 minutes.
D) one breath every 5 to 6 seconds, 300 mg of amiodarone, and transcutaneous cardiac pacing.
C) ventilations at a rate of 10 breaths/min and 1 mg of epinephrine 1:10,000 every 3 to 5 minutes.
Pulseless electrical activity (PEA) refers to the presence of an organized cardiac rhythm (except V-Tach), despite the absence of a pulse; it can result from a variety of conditions, such as hypovolemia, overdose, hypothermia, and trauma, among others. Treatment for PEA includes high-quality CPR with minimal interruptions, 1 mg of epinephrine 1:10,000 every 3 to 5 minutes, advanced airway management, and treating potentially reversible causes. After an advanced airway device is in place, perform asynchronous CPR; the compressor delivers 100 to 120 compressions/min and the ventilator provides 10 breaths/min (one breath every 6 seconds). Do not hyperventilate the patient; doing so may impair venous return to the heart and decrease cardiac output. A ventilation rate of 12 to 20 breaths/min is appropriate for infants and children who are apneic, but have a pulse. An apneic adult with a pulse should be ventilated at a rate of 10 to 12 breaths/min. Dopamine is not indicated for patients in cardiac arrest, and current evidence does not support the use of transcutaneous cardiac pacing (TCP) in patients with PEA or asystole. Amiodarone is indicated for refractory V-Fib or pulseless V-Tach; it is not indicated for PEA.
10 month old female, presenting with wheezing/crackles. Time of year is late fall. Pt has moderate retractions, tachypnea and diffuse wheezing
Bronchiolitis
Difficult to distinguish from asthma. One clue is the child’s age: asthma is rare in children younger than 1 year. An infant with a first-time wheezing episode occurring in late fall or winter likely has bronchiolitis
the organism that causes Epiglottitis
Infectious organism: Haemophilus influenzae Type B
The most serious/lethal complication of alcohol withdrawal
Delirium Tremens
Symptoms start 48-72 hours after last drink
S&S: confusion, hallucinations, tremors, restlessness, fever, diaphoresis, tachycardia and hypotension
The appropriate second dose and method of administration of amiodarone for a patient with refractory ventricular fibrillation is:
A) 150 mg via rapid IV/IO push.
B) 300 mg via rapid IV/IO push.
C) 300 mg given over 10 minutes.
D) 150 mg given over 10 minutes.
A) 150 mg via rapid IV/IO push.
Which of the following is an absolute contraindication for fibrinolytic therapy?
A) Subdural hematoma 3 years ago
B) BP of 170/100 mm Hg on presentation
C) Current use of anticoagulant medication
D) Ischemic stroke within the last 12 months
A
pH: 7.52
PaCO2: 61 mmHg
[HCO3-]: 48 mEq/L
metabolic alkalosis, partially compensated by a respiratory acidosis
4 year old male presenting with acute productive cough of copious thick, pus-filled secretions/stridor and respiratory distress. Febrile and in sniffing position.
What is the most likely cause?
1. Epiglottitis
2. Croup
3. Bacterial Tracheitis
4. Upper airway obstruction
Bacterial tracheitis is an acute bacterial infection of the subglottic area of the upper airway
Which of the following medications is classified as a tricyclic antidepressant?
A) Fluoxetine hydrochloride
B) Nortriptyline hydrochloride
C) Buspirone hydrochloride
D) Midazolam hydrochloride
B) Nortriptyline hydrochloride
Nortriptyline (Pamelor), amitriptyline (Elavil), and clomipramine hydrochloride (Anafranil) are commonly prescribed tricyclic antidepressant (TCA) medications. Fluoxetine hydrochloride (Prozac) is a selective serotonin reuptake inhibitor (SSRI) that is also used to treat depression as well as obsessive-compulsive disorder. Midazolam hydrochloride (Versed) is a benzodiazepine sedative-hypnotic. Buspirone hydrochloride (Buspar) is an anxiolytic medication.
An older man is suddenly awakened in the middle of the night, gasping for air. He is extremely restless and pale, and is coughing up blood. His clinical presentation is MOST consistent with:
A) unstable angina.
B) gastrointestinal bleed.
C) left side heart failure.
D) right side heart failure.
C) left side heart failure.
Waking up in the middle of the night with severe difficulty breathing (paroxysmal nocturnal dyspnea [PND]) and coughing up blood or blood-tinged sputum (hemoptysis) are consistent with left-sided heart failure and pulmonary edema. Right-sided heart failure typically does not present with respiratory distress; it commonly manifests with jugular venous distention and peripheral edema.
A patient experiencing a right ventricular infarction would be expected to present with:
A) hypertension and tachycardia
B) ST elevation in leads II, III, and aVF.
C) greater than 2-mm ST depression in lead V1.
D) severe pulmonary edema and hemoptysis.
B) ST elevation in leads II, III, and aVF.
A right ventricular infarction (RVI) should be suspected when a patient presents with ECG changes indicative of an inferior wall injury pattern (equal to or greater than 1-mm ST elevation in leads II, III, and aVF; reciprocal ST depression and T wave inversion in leads I and aVL) AND has equal to or greater than 1-mm ST elevation in lead V4R when a right-sided 12-lead ECG is obtained. Patients experiencing an RVI are preload dependent and often present with hypotension; therefore, vasodilators (eg, nitroglycerin, morphine) should be avoided. Instead, IV fluid boluses should be given to maintain adequate perfusion. Other signs of an RVI include jugular venous distention and peripheral edema. Pulmonary edema and coughing up blood (hemoptysis) are indicative of left ventricular failure.
8 month old male, pt's mother states pt had a cough at 0800 and suddenly got lethargic over the last 3 hours- EMS activated. Exam - pt lacks tone, not tracking EMS. No adventitious sounds heard from airway. RR is elevated, pt is hot to touch. You notice pt drooling with purposeful hyperextension. What is the most likely disease
Epiglottitis
Differentiating factors - quick onset, drooling, fever and purposeful hyperextension
-Severe rapidly progressive infection of epiglottis and surrounding tissues that may become fatal because of sudden resp obstruction.
Name the signs of respiratory failure (categories of answers - mental status, skin color, RR- trend, Resp effort, auscultation, SPO2- despite O2, pulse rate-trend)
Mental status: Agitation, restlessness, confusion, lethargy (VPU components of the AVPU scale)
Skin color: Central cyanosis despite oxygen administration, pallor
Respiratory rate: Tachypnea → bradypnea → apnea
Respiratory effort Severe retractions and accessory muscle use, nasal flaring, grunting, paradoxical abdominal motion, tripod positioning
Auscultation: Stridor, wheezing, crackles, or diminished air movement
SPO2: low despite O2
Pulse Rate: tachycardia to bradycardia
What syndrome results in the following: Confusion/Agitation/anxiety/SEIZURES, hyperthermia, sweating, Sinus Tach, tachypnea, hypertension, dilated pupils, muscle rigidity (legs), ataxia, hyperactivity, myoclonus
Serotonin Syndrome
When treating an adult patient with a blood pressure of 60/40 mm Hg, confusion, a heart rate of 40 beats/min, and sinus bradycardia on the cardiac monitor, you should administer supplemental oxygen, establish vascular access, and then:
A) administer 0.5 mg of atropine sulfate and consider transcutaneous cardiac pacing.
B) begin a dopamine infusion to increase blood pressure and improve cerebral perfusion.
C) administer sequential crystalloid fluid boluses until his BP is greater than 100 mm Hg.
D) acquire a 12-lead ECG, which may reveal signs of acute myocardial ischemia or injury.
A) administer 0.5 mg of atropine sulfate and consider transcutaneous cardiac pacing.
A patient who presents with or develops symptomatic bradycardia needs to be treated in a manner that will increase the heart rate, thus improving cardiac output, blood pressure, and mental status. Altered mental status, hypotension, chest pain or pressure, and shortness of breath are indications for treatment of the bradycardic patient. After ensuring adequate oxygenation and ventilation, establish vascular access and give 0.5 mg of atropine; this may be repeated every 3 to 5 minutes to a maximum dose of 3 mg. If the patient is severely compromised or does not respond to atropine, begin transcutaneous cardiac pacing (TCP) without delay. If the patient is in a second-degree type II or third-degree AV block, TCP is the first-line treatment. Atropine and TCP-refractory bradycardia may require a sympathomimetic infusion, such as epinephrine or dopamine. The body's normal physiologic response to hypovolemia is tachycardia, not bradycardia. Therefore, fluid boluses are not the initial treatment for the hypotensive, bradycardic patient. In fact, they may cause further harm to the patient. With a slow heart rate and decreased cardiac output, a sudden increase in preload may result in acute pulmonary edema. After stabilizing the patient's heart rate and improving perfusion, obtain a 12-lead ECG to assess for signs of acute myocardial ischemia or injury.
A 35-year-old female experienced a syncopal episode shortly after complaining of palpitations. She was reportedly unconscious for less than 10 seconds. Upon your arrival, she is conscious and alert, denies any injuries, and states that she feels fine. She further denies any significant medical history. Her vital signs are stable and the cardiac monitor reveals a sinus rhythm with frequent premature atrial complexes. On the basis of this information, which of the following would be the MOST likely cause of her syncopal episode?
A) sudden increase in cardiac output
B) Paroxysmal supraventricular tachycardia
C) A brief episode of ventricular tachycardia
D) Aberrant conduction through the ventricles
B) Paroxysmal supraventricular tachycardia
Syncope (fainting) of cardiac origin is caused by a sudden decrease in cerebral perfusion secondary to a decrease in cardiac output. This is usually the result of an acute bradydysrhythmia or tachydysrhythmia. In this particular patient, the presence of frequent premature atrial complexes (PACs), which indicates atrial irritability, suggests paroxysmal supraventricular tachycardia (PSVT) as the underlying dysrhythmia that caused her syncopal episode. In PSVT, the heart is beating so fast that ventricular filling and cardiac output decrease, which results in a transient decrease in cerebral perfusion.