4. Respiratry Emergencies Notes
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Transcript of 4. Respiratry Emergencies Notes
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Upper Airway Pathology Stridor Foreign BodiesAngioneurotic oedemaEpiglotitisCroupRetro-pharyngeal or peritonsilar abscessTrachitis Hypocalcemia, tumours, vocal cord palsyLower Airway Pathology Rhonchi, crepitations, BB, Bronchial AsthmaBronchiolitisPneumoniaTension PneumothoraxFBRespiratory emergencies Dr Rasnayaka M MudiyanseScope of the lecture
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Respiratory distressRespiratory failureEffortsRR, Recessions, Grunting, head noddingEffects On CNS and CVSEfficacy Air entry, chest expansionOxygen saturationCarbon dioxideTreatments
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Below 85% . Below 90 % .Below 95%.Above 95%.
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1.
2.
3.
4. Causes of NON respiratory tachypnea
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List causes of acute stridor 1. 2. 3. 4. 5. 6. 7.
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Causes Viral Allergic spasmodic croup Bacterial Foreign BodiesURTI 1-3 days Fever, rhinorhea & coughBarking cough , Stridor , mild increased respiratory rate, recessionsProgress to severe disease Respiratory distress, increasing respiratory rate, nasal flaring, retractions, respiratory failure
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1. 2. 3. 4. 1.2.5. 6. 7.
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Homophiles Influence BSudden onset, rapid progress, neck is hyper extendedToxic, Sick, Drooling, Febrile ,Reduced voiceDONT disturbX-ray lateral thumb sign
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1.2.3.4.5.6.
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Staphylococcus aureus, moraxella catarhalis, H influence Croup, Toxic but no drooling, can lie flat , no dysphagiaSwelling at cricoid cartilage levelMist and adrenaline not effectiveAntibiotics, tracheostomy sos
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CausesDrugs Penicillin, radio contrast, ARV, AVSFoods Nuts, fish, meat, ApplicantsLook for Upper airwayLower air wayCirculatory
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1.2.3.4.5.6.
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Retropharyngeal LN - Satph, strep, Anaerobs, H Influenzae, KlebsiellaAge 3-4 years M>FHigh fever, drooling, neck stiffness, torticollisUpper airway obstruction , rupture and aspiration pneumonia, extension to mediastinum, thrombophlebitis of internal jugular vein embolism to lungs.X ray neck lateral Widening of retropharyngeal space more than 2/3 of a vertebral bodySurgical drainage Antibiotics Cefuroxime + Cloxacillin
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Age group below 2 yrsSevere 1-3 moPremature babiesPre-existing lung diseaseCHDImpaired immunityCauses RSV > 50%, Adeno, Influencea, ParainflueceaClinical features Tachypnoea, HyperinflationAdmit - Sick baby, Feeding effected, Maternal concernRecognize mild moderate ad severe bronchiolitis
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Mild bronchiolitis
1. Normal ability to feed2. Little or no respiratory distress3. No requirement for oxygen ( SaO2 > 95%)4. No risk factorsTreatment for Mild bronchiolitis1.2.
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Treatment for Moderate Bronchiolitis1.2.3.4.5.
Recognition of Moderate BronchiolitisRespiratory distress + ; RR > 50/minNasal flaringFeeding difficulty +Episodes of apneaRequirement for oxygen ( SaO2 < 92%No risk factors
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Recognize Severe Bronchiolitis Unable to feed Severe respiratory distress Increasingly tired Prolong apnea Hypoxemia PaO2 < 92% Treatment1.2.3.4.5.6.
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Ventilation IndicationsRecurrent apnoeaExhaustionHypercapniaHypoxaemiaConsider C x R & Antibiotics
* Exclude Heart Failure and Pneumothorax
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Causes Pneumococci, Streptococci, Haemophilus influencae, Mycoplasma,E Coli, Staph, Clamidia Clinical featuresFever, Tachypnoea, Pleuratic chest pain abdominal pain, Grunting, Flaring of alea nasi
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Asses severityABC care Oxygen, Fluids (restricted amounts)Antibiotics ( Ampiciline/Cefolosphorine , Erythro 7-10 days)Antibiotics for fever and Tachypnoea -WHOI.C.U. and Ventilator care
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ClinicallyWheezingCoughingSOBPathologicallyBronchospasmsMucosal oedemaSecretions
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Acute asthma- Exacerbations Mild Moderate SevereLife threateningChronic Asthma-Grading Mild intermittentMild persistingModerate persistingSevere persistingChild with any grade of asthma can have mild moderate or severe exacerbations
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Feeding/Activity normalNo audible wheezingNot using accessory musclesNo chest windrowingRR < 50HR < 150
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Feeding activity disturbedAudible wheezing presentUse of accessory musclesChest in-drawing presentRR>50/minHR> 150/minSaO2 < 92%
- Unable to talk / feed Recessions and use of accessory musclesRR > 50 /minHR > 150 minPEFR < 50 %PaO2
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Depressed LOC/ Agitated, DrowsyExhaustion Cyanosis or Saturation in air < 85%Poor respiratory effortSilent ChestPEFR < 33% of expected/ best Poor response to repeated doses of bronchodilators
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Beta 2 agonists - oral or inhalerOral theophylines
Check precipitating factorsDoes he need a preventor?Patient education
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Beta 2 agonists Inhaler or NebulisedTheophylinePrednisolone 2mg/kg/day 3-5 daysReassess in 30-60 min Home/wardPrecipitating factorsPatient educationDoes he/she need a preventor
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Oxygen face mask 6-8 liters/min, nasal prongs 2 liters/minNebulisation with Oxygen every 20-30 min or continuesSalbutamol 2.5 (1/2 cc)- 5mg (1cc) +Ipratropium 250-500 mcg + 2 ml normal salineWhat is the diagnosis ( exclude Heart failure, pneumonia, DKA, bronchiolitis, pneumothorax, FB)What is the severityNeed resuscitation Immediate ABC, bag and maskLife threatening Ward ICUModerate/severe ward Mild OPD Home
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SalbutamolIpratropium bromideBelow 1 yearBelow 5 yearsAbove 5 year
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IV Aminophylin 5mg/kg in 2ml/kg N.Saline bolus/30mt 1mg/kg hrly IV Hydrocortisone 4mg/kg 6 hrly or 1mg/kg/hr IV AntibioticsIV fluids add potassium I.C.U. care IV Salbutamol 15 mcg/kg over 10 min 1-5 mcg/kg/minIV Magnesium sulphate 20- 100 mg/kg over 20 min, 6 hrlyAdrenaline 10 mic/kg sc ( 0.01ml/kg of 1:1000)IPPVMaintain SaO2 above 92%
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Bronchial asthma - NO response to initial treatment , Consider following possibilities 1. 2. 3.4.5.6.
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Suspect when Unequal Physical Signs Sudden onset, Unexplainable No responds to treatment
Treat by Needle thoracocentasis Chest drain
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Indications for ventilation
PCO 2 > 8kpaHypoxia Po2 < 8kpaIncreasing exhaustion
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Precipitating factors ?Prevention step?Home management Policy- Salbutamol via spacer Patient educationInhaler techniquesCounseling and psychological issuesDiagnosis
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DEFINITIVE CARE
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Causes of recurrent wheezingIntra bronchial foreign bodiesRecurrent LRTIMediastinal massesHeart failureGastro oesophagial reflux
H type gastro oesophagial fistula Immune deficiencyLoeffler syndromeVascular rings, Cystic fibrosis, Cilliary dyskinesia
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Step and treatmentDay time SymptomsNight symptomsMild intermittent Step oneSymptoms less than twice/wkNo interval symptoms, Brief exacerbations Varying intensityless than twice/moMild persistent Step twoMore than twice /wk but less than once/day Exacerbations affect the lifemore than twice a moModerate persistent Step threeDaily symptoms Exacerbation more than twice /wk last daysmore than once a weekSever persistentStep fourContinuous symptoms Limited physical activity Frequent exacerbations Frequent
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Step and treatmentDay time SymptomsNight symptomsMild intermittent Step one Once a weekOnce /moMild persistent Step two2-7 /week 2-4/ moModerate persistent Step threeDaily symptomsmore than once a weekSever persistentStep fourContinuous symptoms Frequent
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Mild intermittentLong term control No daily medicationQuick relief for exacerbationsSalbutamol or TurbutalineEducationFacts about asthmaInhaler techniqueAvoidance of precipitating factorsManagement of exacerbationsRecognition of acute severe asthma
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Mild persistentLong term control Inhaled steroids low doseBeclamethasone 50-200 micg per dayBudesonide 100 200 micg per dayFluticasone 100- 150 micg per dayEducationFacts about asthmaInhaler techniqueAvoidance of precipitating factorsManagement of exacerbationsRecognition of acute severe asthma
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Moderate persistentMedium dose steroids Beclamethasone 200- 400 micg/dayBudesonide 200 600 micg/dayFluticasone 200 400 micg/dayORLow dose steroids + Long acting beta 2 agonist
For night symptomsLong acting beta agonists - inhaled or oralSustained release theophylineEDUCATION and counseling
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Severe persistentHigh dose steroids + long acting bronchodilatorsBeclamethasone > 400 micg/dayBudesonid > 600 micg/dayFluticasone > 400 micg/dayLong acting oral beta 2 agonistsSustained release theophylinesOral steroidsEducation and counseling
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Other drugs for asthma control
KetotifenSodium cromoglycateLeukotrene receptor antagonistsMontelucastZafirlukast
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For Successful Asthma ControlPatient educationAbout the diseasePrecipitating factorsRecognition of acute severe asthmaHome management of acute severe AsthmaInhaler techniqueEncouragements and appreciationsConfidence building - Control is possibleFrequent monitoring