Physio
Which of the following represents increased dead space ventilation?
A. ARDS
B. Cyanide toxicity
C. PE
D. Pulm hemorrhage
E. Pneumonia
What is c. PE?
inc dead space ventilation with high V/Q ratio. area of lung receiving oxygen but due to thrombotic obstruction of pulm vessels, there is an area of underperfusion. the rest have low V/Q ratios impaired ventilation (or oxygentation)
The following are indications for a thoracotomy EXCEPT:
a. bleeding that continues at rate > 1-2 mL/kg/hr
b. rib fracture leading to laceration of internal mammary arteries
c. inability to expand the lung
d. retained blood in pleural cavity
e. loss of pulses in ED
What is B- bleeding from internal mammary or intercostal arteries usually minor --> describes hemothorax (initial treatment THORACOSTOMY)
Describe the location of chest tube placement (thoracostomy tube)
What is the 5th IC space mid-axillary line?
Which of the following is least efficacious in treating acute COPD exacerbation?
a. albuterol
b. ipratropium
c. magnesium
d. steroids
e. suppl oxygen
what is c. magnesium ?
This bacteria is associated with a pseudomembrane formation and a bull neck. 50 pt Bonus- what is tx?
What is Corynebacterium diphtheriae? Tx involves IV equine antitoxin + antibiotics (emycin + penG)
Which of the following statements is correct with regards to how the following situations affect PAO2 or A-a gradient?
a. inc person's Hb will inc PAO2
b. inc resp rate will inc PAO2
c. lower altitude will dec PAO2
d. high altitude will dec PAO2
e. Supplying suppl O2 always significantly inc PaO2
What is d. high altitude will dec PAO2
partial pressure of inspired oxygen PiO2 and barometric pressure will dec as you ascend.
Aortic injury should be suspected with all of the following findings EXCEPT:
a. paraplegia
b. hypotension
c. right-sided hemothorax or pleural effusion
d. children with rapid deceleration (high speed MVC or fall from significant height)
e. diminished pulses in LE compared to UE
C. should be LEFT-sided hemothorax or pleural effusion a/w aortic injury
Gastric contents in the chest tube are most suggestive of what thoracic trauma injury?
What is esophageal rupture?
next steps include confirm dx with esophagram. Ensure adequate fluid resuscitation and broad-spectrum antbx.
In distinguishing COPD from CHF exacerbations, which of the following clinical or lab features is helpful?
a. peripheral edema
b. history of COPD
c. distended neck veins
d. body habitus
e. BNP level
e. BNP level
released from L ventricle in response to cardiac stress
What is cellulitis to the floor of the mouth which progresses to thrombophlebitis, carotid rupture and mediastinitis?
What is Ludwig angina?
You receive a phone call from Dr. Martinez that a patient with acute resp failure secondary to acute asthma exacerbation was intubated. He wants to know your recs for initial ventilator settings.
a. decrease inspiratory flow rate
b. use TV 10-15cc/kg idea BW
c. use TV 6-10 cc/kg of ideal BW even if mild resp acidosis
d. maintain higher resp rate bc patient had rapid shallow breaths before intubation
e. maintain high resp rate to decrease CO2, which was retained during exacerbation
C. TV 6-10cc/kg
permissive hypoventilation initially- PEEP 0 (avoid extrinsic PEEP due to air trapping/auto-PEEP, increased inspiratory flow rate (for low insp-exp ratio to inc exp phase), low resp rate (avoid breath stacking). Inc TV may predispose to barotrauma from intrinsic peep
Thoracostomy tube was inserted into teenager with a large pneumothorax. There was a gush of air noted with insertion. Which of the following complications should you watch for in this patient?
a. Hemothorax from injury to intercostal vessels
b. Infection of thoracostomy site
c. mucous plugging of thoracostomy tube
d. persistent air leak and reexpansion pulm edema
e. tension pneumothorax
what is d. persistent air leak and reexpansion pulm edema?
reexpansion pulm edema more often seen in young adults and with large PTX present for >72h that are rapidly expanded with suction. pulm edema generally occurs on the side of reexpanded lung. tx with supportive care and aggressive fluids.
Before performing a tube thoracostomy, a finger should be inserted and palpate to avoid missing this type of injury?
What is a Diaphragmatic injury (scaphoid abdomen, bowel sounds over thoracic cavity)
70yo M with 40 pack-yr smoking history presents with worsening SOB over past 2 days. He has tried using his "orange" inhaler and inc flow on home O2 with no improvement. On exam, appears anxious with retractions and T 37.4, RR 16, HR 110, bp 110/60, SpO2 92% on 2L NC. Which of the following will improve his WOB acutely?
a. Albuterol 2.5mg neb
b. Ipatropium 0.5mg neb
c. NIPPV
d. 100% O2 by NRB
e. IV solumedrol 125mg
What is the cause of an afebrile illness with repetitive paroxysmal cough at 2 weeks of life?
Chlamydia trachomatis
A patient arrives with respiratory distress. You obtain an ABG and discover an elevated A-a gradient. Which of the following conditions can explain the discrepancy?
A. Anemia, Hb <10
B. TOF
C. Opiate OD
D. Interstitial lung disease
E. Severe upper airway compromise due to severe croup
What is D. Interstitial lung disease.
Impediment to oxygen diffusion across alveolar membrane and thus lead to decrease in partial pressure of oxygen.
Findings suggestive of tracheobronchial injury include all of the following EXCEPT:
a. persistent high volume air leak from chest tube placed for pneumothorax
b. subcutaneous emphysema and stridor
c. CXR with hyoid bone elevation
d. left apical cap- fluid from left mediastinum to the apex
e. CXR with obstruction of air-filled bronchus
what is d. L apical cap (seen with aortic injury). For suspected tracheobronchial or aortic injuries, next step is obtaining chest CTA or TEE.
Describe the process of a pericardiocentesis?
What is insert a 20-gauge spinal needle below the xiphoid process at a 45-degree angle toward the left shoulder and blood from pericardial sac does not clot. Dynamic US guidance can help assure proper placement of the needle. Continuous EKG monitoring can be used as well, as a current should be noted on the EKG monitor if the needle touches the heart.
35yo M presents to the ED with sudden onset of chest pain. The patient has a history of substance abuse. On exam, chest wall is tender to palpation. ECG nml. US demonstrates absence of lung sliding. What is the patient's diagnosis?
A. Abscess
B. Contusion
C. Hemothorax
D. Pneumothorax
E. Rib fracture
What is d. pneumothorax?
Infectious process with septic pulmonary emboli and tender neck?
What is Lemierre's?
What is the term to describe blood pressure falling more than 10 mmHg during inspiration?
what is pulsus paradoxus? Occurs in less than 1/2 of patients with pericardial tamponade
List the 3 components of Beck's triad
What is hypotension, JVD, muffled heart sounds? Seen during cardiac tamponade
How can you distinguish blood aspirated from the pericardial sac?
What is blood aspirated from the pericardial sac can be differentiated from intracardiac blood because pericardial blood is defibrinated and does not clot.
What is the primary reason that patients with brisk hemoptysis require emergent airway management?
a. asphyxiation
b. aspiration
c. exsanguination
d. infection
e. nausea and vomiting
from obliteration of airspaces due to blood
What do you see on US in bronchiolitis?
Subpleural consolidations