Pathology Review

Pathology Review

LindseyJones

Emphysema

Defined: Abnormal condi-tion of the alveoli result-ing destruction and lossof elasticity.

Information Gathering

Visual AssessmentCyanosisBarrel chestAccessory muscle useDigital clubbing of the nail bedsSignificant history of smoking and/or occupational exposure to smoke or other

pulmonary irritant

Bedside (Patient Contact) AssessmentDyspnea

Basic Laboratory AssessmentChest X-rayincreased AP Diameter, flattened diaphragms, hyperlucency,

diminished pulmonary markings.CBCpolycythemia, increased WBC due to possible infection.ABGsCompensated respiratory acidosis (high PaCO2, normal pH), moderate to

severe hypoxemia.Sputum cultureoften positive for bacteria.

Special AssessmentsPFTflows are decreased especially middle sized airways (FEF 25-75%) and FEV1

Decision Making

Oxygen therapylow FIO2 (0.24 to 0.28) or 1 to 2 lpm nasal cannula

Oxygen conserving devices such as liquid oxygen or trans-tracheal oxygen

Home care education on devices and equipment cleaning

Rehabilitation efforts (specifics not usually required)

Aids to help quit smoking such as nicotine replacement therapy

Bronchodilation medication via MDI or aerosol nebulizers

What to expect

You will usually be tempted toutilize high FIO2 because of theseverity of the hypoxemia. Youmay also be tested with an emer-gency, the only time it is appropri-ate to use 100% oxygen on achronically obstructed patient.

There are usually two obstructivesimulations on the exam and theyare not extremely challenging.

Chronic Bronchitis

Defined: Condition wherethe patient has a produc-tive cough 25% of theyear for at least two con-secutive years


Visual AssessmentProductive cough, purulent sputum productionExposure to pulmonary irritants, like history of smokingFrequent infections


Basic Laboratory AssessmentChest X-raycould be normal, or may show hyperlucency, diminished \

pulmonary markings.CBCpossibly increased WBC due to possible infection.ABGscould be normal or very slight respiratory acidosis and hypoxemia

Special AssessmentsPFTflows are decreased especially middle sized airways (FEF 25-75%) and

FEV1

Decision Making

Anything that promotes good pulmonary hygiene such as chest physiotherapy, hydrationtherapy when sputum is thick.

Fluid therapy if dehydrated.

Oxygen therapy for hypoxemia

Aerosolized bronchodilator therapy

Antibiotic Tetracycline may be preferable

What to expectThe most distinguishing charac-

teristic is that the cough is produc-tive and has been so for a good

portion of the year.

Bronchiectasis

Defined: Abnormal condi-tion where the bronchisecrete large volumes ofpus during abnormal dila-tion


Visual AssessmentProductive cough, often with bloodDigital clubbing of the nail bedsSignificant history if infections (recurrent)


Basic Laboratory AssessmentChest X-raygenerally normalSputum culturegram negative bacteria

Special AssessmentsBronchogram is the primary test. Characterized as a tree in winter pattern

Decision Making

Anything that promotes good pulmonary hygiene such as chest physiotherapy, hydrationtherapy when sputum is thick.

Fluid therapy if dehydrated.



May have consider surgical intervention on some highly affected segments

What to expect

Central to this is the Bronchogramdiagnostic test. Usually, you willbe told of the suspicion of Bron-chiectasis.

Increasingly less common on thetest

Obstructive Sleep Apnea

Defined: the cessation ofbreathing during sleep.Is usually obstructive innature but sometimescan be central or a com-bination of the two(mixed).


Visual AssessmentSpouse or bed partner will complain of snoring and will often report witnessing

periods of apnea that exceed 10 seconds.Excessive upper airway tissue, obesity, thick neckAbility to fall asleep quickly

Bedside (Patient Contact) AssessmentDyspneaFrequent urination during sleeping hours

Basic Laboratory AssessmentABGscould be normal or very slight respiratory acidosis and hypoxemia

Special AssessmentsPolysomnography (Sleep study) - determines if obstructive or centralIf no nasal flow AND no chest movementthen CENTRAL sleep apneaIf no nasal flow WITH chest movementthen OBSTRUCTIVE sleep apnea

Decision Making

If central, ventilatory stimulant medication may be used

If obstructive, use of CPAP or BiPAP is usually initially indicated with follow-up weightloss or upper airway tissue removal through surgery.

Problem must be corrected immediately, so even if discharging, send devices home withpatient. In the absence of a titration study, initially ordered pressure should be 10 to 20 cmH20.

What to expectThis is still somewhat rare on the

test but it does show up.

It is important to remember toavoid sending the patient home

without some sort of ventilatorysupport.

Asthma

Defined: Abnormal con-striction of the bronchialsresulting in sputum pro-duction and narrowedairways.


Visual AssessmentAccessory muscle useTachycardia

Bedside (Patient Contact) AssessmentDyspneaWheezingCongested coughWet, clammy skin

Basic Laboratory AssessmentABGspossible respiratory acidosis, could be hypoxicChest X-rayhyperinflation, scattered infiltrates, flattened diaphragms.In allergic cases, may see elevated eosinophil count which can cause yellow sputum

Special AssessmentsPFTDecreased flows in FEV1 but diffusion is normal as manifested by DLCO

Decision Making



Xanthine medication given IV (Aminophylline, etc)

Promote pulmonary hygiene

Corticosteroids such as oral or IV prednisone

What to expect

When doing PFTs, always do apre and post bronchodilator study.Consider effective if 15% or moreimprovement is noted.

There are no significant traps inthis simulation except that thepatient may be unresponsive tobronchodilators. In such a case,you are dealing with Status Asth-maticus. Refer to that disease

Status Asthmaticus

Defined: Asthma that willnot respond to bron-chodilation therapy, usu-ally persists more than24 hours.


Visual AssessmentHistorically non-responsive to bronchodilators. Patient will report the need to

take many bronchodilator treatments before feeling better.Accessory muscle use and retractionsDyspneaWheezingCongested coughWet, clammy skin

Bedside (Patient Contact) AssessmentPulses paradoxus

Basic Laboratory AssessmentABGspossible respiratory acidosis when tiring, alkalosis at first due to anxiety,

could be hypoxicChest X-rayhyperinflation, scattered infiltrates, flattened diaphragms.

Special Assessments

Decision Making

May deteriorate quickly, so if progression is shown, intubate, mechanically ventilate be-fore full ventilatory failure.

Use subcutaneous epinephrine1 mL of 1:1000 strength. May need to give every 20minutes for up to three consecutive doses

What to expectThis simulation will challenge

your ability to recognize impend-ing ventilatory failure. It is veryimportant that you treat it before

full ventilatory failure.

There is a frequent need to repeatactions in this simulation which

will make you uncomfortable. Donot be afraid to administer several

bronchodilators in succession.The same is true of the subcutane-

ous epinephrine. If you give onedose, you will likely have to give

another, and possibly another.Continue if symptoms show no

signs of relief.

Myasthenia Gravis

Defined: Neuromuscularabnormality where mus-cles experience paralysisstarting from the headdown to the feet includ-ing ventilatory muscles.


Visual AssessmentMay have a history of Myasthenia Gravis if not the onsetDroopy facial muscles and eyelids (Ptosis)

Bedside (Patient Contact) AssessmentPatient will describe slowly feeling weakness generally but feels better with rest.Double vision (diplopia)Dysphagia (difficulty swallowing)Shrinking Vt, VC, MIP

Basic Laboratory Assessment

Special AssessmentsTensilon Challenge Testpositive for Myasthenic crisis if improvement is noted

upon the administration of Tensilon

Decision Making

If Tensilon improves condition then, anticholinesterase therapy is indicated including:

Neostigmine (prostigmine)Mestinon (pyridostigmine)

Ok to do additional Tensilon challenge test to observe progression.

If symptoms improve with Tensilon and then worsen, the must reverse the anticholinesterasewith Atropine.

Always monitor spontaneous ventilatory volumes (Vt and VC) as well as MIP.

Never treat Myasthenia gravis with Tensilononly use to diagnose. Use the above men-tioned drugs to provide maintenance.

Be totally prepared to intubate and mechanically ventilate prior to Tensilon challenge since itcould take out the respiratory drive

When VC falls off rapidly (especially if below 1.0 L) , then intubate and mechanically venti-late.

What to expect

This can be a very tricky simula-tion and it is likely that it willshow up on the exam. Especiallyimportant is your use of Tensilonto diagnose it and an understand-ing of the dangerous affects itcould have. Must always be pre-pared to assume ventilation.

Vt, VC, and MIP are key in moni-toring this patient for degradationin ventilatory status. Intubateprior to full failure if possible.

Drug Overdose

Defined: Potential loss ofventilatory drive as a re-sult of drug overdose(usually a narcotic)


Visual AssessmentHistorical drug use as told by previous admissions or familySometimes poor self-hygiene, emaciated

Bedside (Patient Contact) AssessmentLook and act sleepy, difficult to arouseRespiratory rate and pattern is low and/or shallow

Basic Laboratory AssessmentABGoften show pure respiratory acidosis and/or ventilatory failure

Special Assessments

Decision Making

#1 priority in this case is intubation to protect the airway, prevent aspiration of stomachcontents, and facilitate manual ventilation.

If narcotic overdose (usually is) then use narcotic reversing medication such a Narcan(Nalaxon)

Support ventilation until drugs are out of system.

What to expectThe most important part of this

simulation is the need for immedi-ate intubation while recognizing

that there may not be a need tomechanically ventilate until venti-

latory status deteriorates.

Other Neuromuscular

Defined: Other neuro-muscular diseases orstates include Poliomyeli-tis, Tetanus, Musculardystrophy, and evenbotulism poisoning.


Visual AssessmentHistory of illness

Bedside (Patient Contact) AssessmentShrinking Vt, VC, MIP


Special Assessments

Decision Making

Monitor for ventilatory failure generally through Vt, VC, MIP and ABGs

What to expect

If faced with these diseases, sim-ply apply general respiratorymonitoring principles and facili-tate ventilation when needed.

These are somewhat rare.

Head Trauma

Defined: Potential loss ofventilatory drive as a re-sult of drug overdose(usually a narcotic)


Visual AssessmentSometimes trauma is visual with blood contusions on the headHistory is trauma related, often automobile accident

Bedside (Patient Contact) AssessmentLook and act sleepy, difficult to arouseRespiratory rate and pattern is low and/or shallow and irregularPupillary response to light may be unequal or inadequate


Special AssessmentsIf intracranial pressure monitor is in place, may see ICP greater than 20

cm H2O

Decision Making

Must constrict vessels in the head by keeping PaCO2 between 25-30 mm Hg.

Adjust FIO2 to maintain high normal levels (PaO2 of 100 mm Hg).

Avoid increased ICP by minimizing PEEP usage.

Suction only when needed due to elevating peak pressures.

Avoid anything that will increase mean arterial pressure (MAP).

Sedation is important, but should monitor exhaled volumes and pressures closely

Use of drugs such as Manitol (cerebral diuretic medication) when ICP is above 20 cm H20

Use Dilantin and establish an airway if seizure activity is observed

What to expectUnique to this simulation is the

need to monitor ICP readings andavoid anything that increases

MAP. You will likely need tosuction this patient to keep peak

pressures down but the very act ofdoing so my elevate ICPs.

Chest Trauma

Defined: May any traumaleading to fractured ribsor flail chest


Visual AssessmentCircumstantial history (motor vehicle accident, etc)Respiratory rate and pattern is fast and shallow due to painMay have obvious trauma (bruising) on chest wall

Bedside (Patient Contact) AssessmentSharp chest pain, especially at the top of each breathParadoxical chest movement if ribs are broken in two places (flail chest)Pneumothorax is possible (see signs and symptoms of pneumothorax)

Basic Laboratory AssessmentChest x-raymay reveal broken ribs, usually isolated in same area

Special Assessments

Decision Making

Anything that encourages deep (adequate) breathing in spite of pain such as IPPB, incentivespirometry, coughing.

Watch for ventilatory fatigue and eventual ventilatory failure

Mechanically support ventilation when it is evident ventilatory failure is impending. If possi-ble do not wait until full ventilatory failure.

Treat partial pneumothorax if greater than 20% - ie insert chest tubesTreat hemothorax, with chest tubes or thoracentesisTreat tension pneumothorax with a large-bore needle

What to expect

This case is usually easy to recog-nize. You may be tempted byoptions that address the brokenribs when, in fact, you simplyneed to address ventilation.

Very commonly, this case willlead to pneumothorax or partialpneumothorax or hemothorax.

Hemothorax/Pneumothorax

Defined: Loss of adher-ence of the lung to thepleural wall causing thespace to be filled with airor fluid (bloody).


Visual AssessmentRapid and shallow respirations

Bedside (Patient Contact) AssessmentPercussion: hyperresonant if pneumothorax, dull if hemothoraxTracheal shift: to affected side if pneumothorax, away if tension pneumothoraxSevere dyspneaVery diminished or absent breath soundsPulses paradoxes

Basic Laboratory AssessmentChest x-raydefinitiveshow hyperlucency, tracheal or mediastinal shift

Special Assessments

Decision Making

Usual treatment is insertion of chest tubesUpper anterior chest tube placement for pneumothorax (involving air)Lower chest tube placement for hemothroax (involving blood and body fluid)

Treat partial pneumothorax if greater than 20% - ie insert chest tubes

Treat hemothorax, with chest tubes or thoracentesis

Treat tension pneumothorax with a large-bore needle

What to expectPneumothorax, hemothorax, ten-

sion pneumothorax occurs veryfrequently on the exam

May include the troubleshootingof chest tube drainage devices

Thoracic Surgery

Defined: Can have vari-ety of complications fromthroacic surgery


Visual Assessment

Bedside (Patient Contact) AssessmentAlways monitoring chest tube drainage adequacyLooking for potential complications:

Hypovolemic shock, low hemodynamic values including blood pressureSubcutaneous emphysemaElevated ventilatory pressures

Basic Laboratory AssessmentChest x-rayto confirm proper re-inflation of the lung and proper placement

of chest tubes

Special Assessments

Decision Making

Anything that promotes expansion of the lungs including incentive spirometry, IPPB, andpositive pressure mechanical ventilation

If a lobectomy or pneumonectomy, ventilatory volumes should set lower

Fluid therapy if volume is a problem (often is).

What to expect

Your ability to deal with and trou-bleshoot chest tube maintenance istested in this simulation.

Sometimes this case is combinedwith chest trauma.

Neck/Spinal Injury

Defined: Any traumathreatening the physicalstructure of the neck.Can include neck or spi-nal surgery.


Visual AssessmentHistorical relevance, some sort of accident such as diving, automobile.Visible damage to the neckAltered conscious levelPulse must be palpated brachially or femorally

Bedside (Patient Contact) AssessmentVt, VC, PEFR, and other ventilatory volumes may quickly deteriorate

Basic Laboratory AssessmentNeck x-raywill show injury

Special Assessments

Decision Making

Always be prepared to quickly assist and/or promote ventilation.

If intubation is required, always use MODIFIED jaw thrust.

If given option, always intubate with a bronchoscope so damage can be visualized andcare can be taken to avoid inflicting further damage.

Alternatively, a blind nasal intubation is acceptable.

What to expectYour knowledge of special intuba-

tion techniques is what is beingtested in this type of simulation.

Abdominal Surgery

Defined: Surgery of inthe abdominal area forvarious reasons.


Visual AssessmentAll general visual assessments

Bedside (Patient Contact) AssessmentAll general beside assessment including all vitals

Basic Laboratory AssessmentVentilatory volumes (VC, Vt, FEV1) compared to pre-surgery baselines

Special Assessments

Decision Making

Establishing baselines in pulmonary function testing flows and volumes.

Start patient on incentive spirometry prior to surgery, every hour after surgery

Use positive pressure (IPPB) if needed after surgery if patient is unconscious.

What to expect

Abdominal surgery is usually avery general, non-complicatedcase involving preventative careand follow up.

Adult Respiratory Distress Syndrome

Defined: A condition thatresults in significantlydecrease lung compli-ance and consequentprofound hypoxemia


Visual AssessmentRecord may show a variety of insults to the lung including massive surgery,

near drowning, inhalation of gasoline, hypothermia, and others.Rapid respiratory rateCyanosis

Bedside (Patient Contact) AssessmentDecreased lung compliance as manifested by increased plateau pressures

(decreasing static compliance)

Basic Laboratory AssessmentABGspersistent hypoxemia in spite of elevated FIO2 (may be refractory)Chest x-rayshow granular, or ground glass, or reticulogranular, or honeycomb

patterns. Often accompanied by diffuse infiltrates.

Special AssessmentsAll hemodynamic values could deteriorate when positive ventilatory pressures

become significant.

Decision Making

As positive pressure is required increasingly, negative effects may be seen. All should bedone to minimize the mean pressure being put on the pulmonary system, while trying tobalance the need to ventilate with higher pressures an utilize PEEP to maintain oxygena-tion.

If underlying cause in know, treat it.

After emergency situation is past, keep FIO2 at 0.6 and use PEEP

Keep increasing PEEP until an obvious degradation in hemodynamic values is witnessed.

As ventilatory pressure get higher, OK to consider alternate methods of ventilation includ-ing pressure control, high frequency, etc

What to expectARDS can be a very disquieting

case to deal with. Usually persis-tent increases in PEEP are needed.Do not be afraid to increase PEEP

significantly.

Also, most often, cardiac outputor some other hemodynamic value

will fall indicating a need to de-crease PEEP in spite of profound

hypoxemia.

Laryngectomy

Defined: Surgery done toaddress or remove can-cer of the larynx.


Visual AssessmentSurgical record : Surgery radical (entire larynx) or simple (cord removal)Medical history will show cancer in upper airway

Bedside (Patient Contact) AssessmentSigns of airway obstruction after surgery. Usually caused by blood within a few

hours after the surgery.


Special Assessments

Decision Making

If radical surgery (entire larynx removed) then the tracheostomy become permanent.

If not radical then a temporary laryngectomy tube is placed but must be replaced in 3 to 6weeks.

Prevent aspiration ! Wait at least a week before oral ingestion of liquid and longer for food.Thorough pulmonary hygiene through suctioning

Use cool aerosol or ultrasonic nebulizer to keep secretions thin and hydrated.

Once the surgery is done, you can no longer, orally intubate the patient. Even if temporarylaryngectomy tube is in place, you must intubate and/or ventilate through that tube !

What to expect

In this case, you are always look-ing for post-surgical complica-tions like blood clots in the laryn-geal tube. Often, you will have tomechanically ventilate this patientthrough the laryngectomy tube.

Guillain-Barre Syndrome

Defined: An insidiousneuromuscular probleminvolving muscle paraly-sis. Paralysis begins inthe lower extremities andmoves upward, includingthe ventilatory muscles.


Visual AssessmentMedical history or patient complaint of recent fluenza-type sickness.

Bedside (Patient Contact) AssessmentComplaint of sluggish lower extremitiesShrinking Vt, VC, MIP

Basic Laboratory AssessmentABGsimpending or current ventilatory failure.

Special AssessmentsSpinal tapwill show increased protein in the spinal fluid

Decision Making

Be primarily concerned with loss of ventilation, monitor ventilatory volumes (VC, Vt) andMIP.

Be patient about intubation and mechanical ventilation. Onset can be slow.

Primary treatment will involve mechanical ventilation and letting the syndrome run itscourse.

What to expectLike most neuromuscular cases,you will be tested in your ability

to recognize deterioration in venti-latory muscles. In this case, onset

can be slow, so dont jump-the-gun and mechanically ventilate

too early. Only do so as VC fallsbelow 1.0 L.

Otherwise, you will be manipulat-ing the ventilator and possibly

weaning.

Shock

Defined: Condition wheretissues oxygenation is injeopardy due to a suddendecrease in blood flow.


Visual AssessmentHistorical evidence of an event or massive trauma or hypothermia, etcGeneral appearancecold, clammy, dusky, cyanoticTachycardia, tachypnea

Bedside (Patient Contact) AssessmentHypotensiveTemperature may be below normalReduction in urine output

Basic Laboratory AssessmentABGshypoxemia and ventilatory failure

Special AssessmentsReduction in common hemodynamic values (CVP, PAP, PCWP) and cardiac output.

Decision Making

Mechanically ventilate with ventilatory failure.

Oxygen is key. Start it as evidence of shock is presented.

Use oxygen at least 40% but may use up to 100%

Main treatment involved treating the original problem (that which caused the shock). Thiscan be highly variable.

What to expect

Shock will test your ability torecognize it and monitor the pa-tient for ventilatory failure. Mostof the simulation is dealing withtypical ventilatory considerationssuch as ventilator manipulation.

Heart Surgery

Defined: Any kind of sur-gery on the heartInformation Gathering

Visual AssessmentDo well rounded assessment prior to surgery including vital signs, family history

of cardiac illness.

Bedside (Patient Contact) AssessmentPreoperative assessments of breath soundsBaseline data including basic spirometry of all types including FEV1/FVC and

pre and post bronchodilator studies

Basic Laboratory AssessmentABGspreoperative for baseline

Special Assessments

Decision Making

Always assess ventilatory volumes and be prepared to mechanically ventilate

Incentive spirometry every hour after surgery for lung expansion and alveolar ventilation.

If unable (unconscious) use simple ventilatory assisting devices such as IPPB or CPAPwith mask.

Be on the alert for cardiac arrestperform CPR without reservation or consideration ofthe heart surgery.

What to expectThis case is not too complicated.You may feel hesitant to do CPRon someone fresh out of surgery.

Just do it.

Pulmonary Edema / CHF

Defined: Significant re-duction in cardiac output.Involvement of fluidpenetrating the alveolarcapillary membrane intothe lungs.


Visual AssessmentHistory of CHF or pulmonary hypertensionTachypnea, tachycardia, anxiety

Bedside (Patient Contact) AssessmentCold, clammy, diaphoreticPink frothy secretionsEdema of fluids (especially pedal edema)Pitting edema (+2, +3)Breath sounds reveal fine, wet rales

Basic Laboratory AssessmentABGsventilatory failure with moderate to severe hypoxemiaChest X-rayButterfly pattern, fluffy infiltrates

Special AssessmentsIncreased hemodynamic pressure (PCWP, PAP, CVP)

Decision Making

Treat as an emergency !

100% oxygen

Administer diuretic medication furosemide (Lasix)

Cardiac intatropic stimulating drugs such as digoxin, digitalis if increased PCWP and PAP

Be prepared to treat ventilatory failure with mechanical ventilation

What to expect

This case may feel complicatedbecause it involves the heart andhemodynamic values. It is usuallyeasily identified by pink frothysecretions and butterfly pattern onthe chest X-ray.

You may need to make the dis-tinction between pulmonaryedema caused by cardiac prob-lems and that which is caused byalveolar capillary membrane prob-lems (ARDS). If it is cardiac,then you must treat the heart.

Myocardial Infarction/Arrhythmia

Defined: Ischemia to theheart causing muscledamage and potentialfailure.


Visual AssessmentHistory of chest pain, radiating pain down the left armFamily history of diseaseDiaphoreticHistory of nauseaTachycardia

Bedside (Patient Contact) AssessmentCold, diaphoretic and clammy to the touchDyspnea

Basic Laboratory AssessmentABGshypoxemiaECG (EKG) - pronounced Q waves and S-T segment elevation

Special AssessmentsCardiac enzymes including CPK, LDH, SGOT are elevated

Decision Making

Emergency100% oxygen.

Oxygen at adult therapeutic level (40 to 60 %) upon suspicion or first presentation so signsand/or symptoms

Treat arrhythmias

Bradycardia with Atropine or IsuprelPVCs with lidocaine or oxygenPulseless ventricular tachycardia with defibrillationVentricular Fibrillation with defibrillation

Note: For Ventricular fibrillation, defibrillate at ascending watt/sec or joule settings360 joulesrepeat as neededDo not exceed 360 joules

Note: For Atrial fibrillation or flutter, do synchronized cardioversionstart at 50 joules

What to expectWill likely need to treat arrhyth-

mias with appropriate medicationand/or defibrillation

Pulmonary Emboli

Defined: Situation wherethe pulmonary artery be-comes obstructed anddead-space ventilationresults. Sometimescalled deadspace dis-ease.


Visual AssessmentHistory of recent major surgery or trauma (amputations, clotted massive bleeding

sights)Complaint of chest pain and dyspnea

Bedside (Patient Contact) AssessmentElevated vitals including pulse, respirations, and blood pressureBreath sounds - wheezing and medium ralesPECO2 (Capnography) decreasing PECO2 during normal PaCO2

Basic Laboratory AssessmentABGspersistent hypoxemia in spite of increasing FIO2

Special AssessmentsV/Q scan will ventilation without adequate perfusion

Decision Making

Anticoagulation therapy with Heparin or CoumadinNote: must monitor clotting tests

PTT for HeparinPT for Coumadin

Clot-busting medication such as steptokinase. May also use a bolus of heparin

Mechanical ventilation as needed.

Emergency level oxygen100%

What to expect

This case primarily involves rec-ognizing the pulmonary emboliand treating it with anticoagula-tion medications. You will likelyhave to monitor clotting times,PTT or PT.

Otherwise, involves general respi-ratory therapy.

Newborn Assessment

Defined: Involves deliv-ery of an infant is compli-cated by various prob-lems


Newborn AssessmentAPGAR 2 points 1 point 0 pointsColor pink pink body blue or pale

blue extremities all over

Pulse above 100 below 100 none

Reflex irritability cough or facial grimace none(Grimace) sneeze

Activity active some flexion limp or no(flexion) movement of limbs movement

Respiratory effort strong cry weak cry no cry

HistoryIf poor APGAR, may be pre-term, congenital heart problem, meconiumaspiration IRDS, transient tachypnea

Other helpful assessmentsGestational ageWeight

Decision Making

If APGAR Score is:

0 to 3 PERFORM CPR

4 to 6 Administer oxygen, place infant in warm, neutrally thermalenvironment, generally stimulate the baby

7 to 10 Monitor normally

What to expectWill commonly have to do an

APGAR score. You may have topick the 5 essential elements from

a list. Dont be tempted by anytests other than APGAR criteria

unless they can be done by simplylooking at the infant.

Or, you may be given the ele-ments and asked what you want to

do about it.

Meconium Aspiration

Defined: Infant born hav-ing meconium in ventila-tion spaces


Visual AssessmentHistory of meconium-colored amniotic fluidOften with full-term infantsInfant may have meconium staining about the bodyMay demonstrate grunting, retractions, nasal flaringPoor color (cyanosis)

Bedside (Patient Contact) AssessmentAPGAR score between 0 and 6

Basic Laboratory AssessmentABGshypoxemia with respiratory acidosis, metabolic acidosis or mixedChest X-rayBilateral densities and widespread atelectasis

Special Assessments

Decision Making

Remove the meconium from the airway. If possible, suction the baby as soon as the headappears from the birth canal.

Intubate to facilitate suctioning

Reintubate if tube becomes clogged for any reason

Mobilize secretions with chest physiotherapy.

Mechanically ventilate only if needed

Apply supplemental oxygen as needed.

What to expect

This is a very common case on thetest. It is fairly straight-forwardand easily recognized. The key tothis is repeated suctioning andclearing of the airway.

Sudden Infant Distress Syndrome

Defined: Sudden apneaoccurring in newborn in-fants as a results of animmaturity central con-trol of ventilation.


Visual AssessmentHistory of pre-term birthFamily genetic predispositionObserved, irregular respirations, bradycardia may increase risk of SIDS

Bedside (Patient Contact) AssessmentCold air on infants face may induce apneaDiminished or absent Moro and Babinski reflexes


Special Assessments

Decision Making

Provide oxygen when in crisis (30 and 50%)

Do not send infant home without an apnea monitor and parental education

If offered, teach parents CPR.

What to expectSomewhat rare case on the test.

Nothing particularly challenging.

Infant Respiratory Distress Syndrome

Defined: Condition in in-fants where alveolus ma-turity is below normal.


Visual AssessmentHistory may show pre-term infantOnset can be immediately after birth or within a few hoursGeneral respiratory distress, ie grunting, nasal flaring, retractionsCyanosis

Bedside (Patient Contact) AssessmentAPGAR score between 0 and 6

Basic Laboratory AssessmentChest-Xrayradiological description such as ground glass, honeycomb,

reticulogranularABGspersistent hypoxemia in spite of elevated FIO2

Special Assessments

L/S ratio2:1 or higher is normal. Less than that shows lung immaturity

Decision Making

Help lung maturity through surfactant therapy with agents like Exosurf or Survanta

2 to 5 ml/kg split among 2 to 4 dosesAdminister directly down the airwayChange infants position after every dose for 30 seconds to distribute

the agent

Provide oxygen via a hood. May use CPAP to oxygenate

Mechanically ventilate with ventilatory failure, use SIMV mode on all infants. May considerreverse I:E ratio

Note: If X-ray changes from signs of IRDS to hyperinflation and fibrosis, then the problemmay have developed into Bronchopulmonary Dysplasia. Treat as prolonged IRDS by:

maintaining pH of 7.25 to 7.40, PaCO2 45 to 60 torr, PaO2 55 to 70 torr. Use low FIO2 Keep mean airway pressure at a minimum Wean only gradually and as tolerated, often fails initial attempts Extubate if respiratory rates are between 5 and 15 breaths

What to expect

This is a common case on the test.Key is remembering to addresslung maturity.

Also, if prolonged ventilation isrequired, Bronchopulmonary Dys-plasia may develop. Be patientand treat moment to moment.

Congenital Heart Defects (Infant)

Defined: Infant is bornwith an anatomical mal-ady of the heart or thevessels that emanatefrom the heart.


Visual AssessmentHistory of pre-term birthGeneral signs of respiratory distress (grunting, nasal flaring, retractions)Cyanosis that persists in spite of high FIO2

Bedside (Patient Contact) AssessmentHeart sounds are abnormal upon auscultation (murmur present)

Special AssessmentsEchocardiogram is the best diagnostic test for all cardiac defects

Decision Making

Specific Defect Attributes

Coarctation of the Aorta (narrowing of aorta)Hypertension in the upper extremities, hypotension in lower extremities

Transposition of the Great VesselsAorta and pulmonary artery are switched.Aorta rising from the right heart, pulmonary artery rising from the left heart

Patent Ductus Arteriosis (ductus arteriosis never closes)Diagnosed by comparing blood gases from the radial artery and the umbilicalartery. Positive for PDA if difference is greater than 15 torr. (PDA with a rightto left shunt)

Other ProblemsTetralogy of Fallot

boot-shaped heart, overriding aortaAtrial septal defect (ASD)Ventricular septal defect (VSD)Truncus arteriosis (pulmonary artery same as aortacombined vessel)

ALL CONGENITAL DEFECTS ARE TREATED WITH SURGERY !!

Prior to surgery simply provide supportive care such as:oxygen to keep PaO2 > 60 mm Hg.mechanical ventilation when ventilatory failure is shown by ABGs

What to expectYour skills in recognizing com-mon congenital heart problems

will be tested.

Otherwise, you will be simplyproviding supportive care until

surgery.

Neonatal Diaphragmatic Hernia

Defined: Condition wherethe diaphragm nevergrows closed. Usuallyoccurs on the left side


Visual AssessmentGeneral respiratory distress, ie grunting, nasal flaring, retractionsCyanosisBarrel chest or scaphoid abdomenMedistinal shift

Bedside (Patient Contact) AssessmentBreath sounds absent (usually on left)

Basic Laboratory AssessmentChest-Xrayshow intestinal parts in the chest area. Also may see a mediastinal

shift away from the affected side.ABGsPoor

Special Assessments

Decision Making

TREATMENT IS SURGERY

Use low ventilatory pressures

Do not use manual bag and resuscitation if possible

May use gastric tube to decompress stomach and intestines.

All other care is supportive

What to expect

This case is more about what youshould not do. Otherwise usegeneral supportive care.

Choanale Atresia

Defined: Infant is bornwith an anatomical mal-ady of the heart or thevessels that emanatefrom the heart.


Visual AssessmentNormal appearing, normal color, cyanosis during feeding

Bedside (Patient Contact) AssessmentDuring breast or bottle feeding, baby becomes apneic and cyanoticSlight inspiratory stridor

Special AssessmentsNeck and chest x-rays rule out airway inflammationDiagnosis by attempting to pass a suction catheter through the nares.If unable to pass, then positive

Decision Making

Care in feeding

Correct with Surgery

What to expectYour skills in recognizing com-mon congenital heart problems

will be tested.

Otherwise, you will be simplyproviding supportive care until

surgery.

Laryngotracheobronchitis

Defined: Otherwiseknown as Croup. Resultsfrom a viral infection thatillicits inflammation in theupper airway.


Visual AssessmentHistory of cold in the past few daysBarking coughAge is 6 months to 3 yearsStridorTachypnea

Bedside (Patient Contact) Assessment

Special AssessmentsLateral Neck X-rayswelling below the glottis sometimes described as steeple

sign or pencil point.

Decision Making

Priorityplacement in an oxygen tent with 30 to 40%

Aerosolized Racemic Epinephrine

Intubation if patient is described as lethargic, markedly diminished breath sounds, severeor marked stridor, extreme accessory muscle use

Extubation should be done when swelling has ceased.

What to expectYou will likely be tempted to treat

this like Acute Epiglottitis in anemergency fashion.

Repeated racemic epinephrinetreatments may make you feel

uncomfortable

Acute Epiglottitis

Defined: Condition wherethe epiglottis and adja-cent upper airway tissuesare infected with a bacte-ria causing inflammationand commonly threaten-ing airway patency.


Visual AssessmentSudden onset of sickness, within 12 hours, often occurs in the eveningAge 3 to 10 yearsGeneral appearance may show drooling, hoarseness, quiet coughMay hear a softened inspiratory stridorTachypnea and tachycardia

Bedside (Patient Contact) AssessmentPatient unable to swallow, will usually not be crying, eyes are bigSignificantly elevated body temperature, taken axillary, or tympanically


Special AssessmentsLateral neck x-ray will show supraglottic inflammation

Decision Making

Primary and immediate concern is establishing and airway as complete closure from inflam-mation. Since inadvertent stimulation from oral intubation attempts could immediately illicitan inflammatory response, intubating in a surgical environment is very helpful. There may beneed to place a tracheostomy tube.

Antibiotic therapy to correct bacterial infection

Oxygen therapy at 30 to 40%

Extubate only when inflammation is gone

What to expect

This case will test your immedi-ately ability to realize that it is anemergency. Stridor may temptyou to treat it more casually likecroup.

There is a good chance you willsee Epiglottitis or Croup on thetest.

Bronchiolitis /RSV

Defined: Acute vital in-fection of lower respira-tory tract usually occur-ring in infants less than18 months old. Com-monly caused by the res-piratory syncytial virus.


Visual AssessmentGeneral signs of respiratory distress including retractions and accessory muscle

use.Tachypnea and tachycardiaHistory of recent sickness from ages 2 months to 3 years old

Bedside (Patient Contact) AssessmentLow grade feverWheezing, rales, and rhonchi

Basic Laboratory AssessmentChest X-ray show scattered infiltrates and hyperlucency

Decision Making

Primary treatment is delivery of the drug Ribavirin which must be administered via aSPAG unit (small volume particle aerosol).

Utilize a scavenger system, filters, and masks.

What to expectThere is nothing particularly diffi-cult about this case. You must beprepared to recommend the use of

a SPAG unit.

Not commonly seen on the exam.

Cystic Fibrosis

Defined: An inheriteddisorder resulting in themass production of thickmucus in the lungs.


Visual AssessmentFamily history of disease, siblings may have it.Emaciated in appearance and body frame may be small or ageSputum production of thick voluminous purulent secretionsCan look like a young COPD patient, barrel-chested

Bedside (Patient Contact) AssessmentDecreased flow rates such as FEV1

Basic Laboratory AssessmentChest X-raylooks like COPD, hyperinflation, increased A-P diameter, diaphragm

flattening

Special AssessmentsSweat Chloride Testshow sweat chloride > 60 mEq/L

Decision Making

Primary treatment relates to the need to mobilize and remove secretions.

Secretion removal promotion therapies:PEP therapy devicesChest physiotherapy with postural drainageHydration devices such as heated aerosol or ultrasonic nebulizationVibration therapy

Oxygen as needed

Antibiotic therapy when infection is presentoften is

Medications used commonly include Tobramycin and Pulmozyme

What to expect

Not commonly seen on the exam.Tests your ability to recognizesecretion removal therapies andmay check your understandingwhen and how to modify therapy.Ex, when CPT doesnt work, usePEP therapy or ultrasonic nebuli-zation.

Hypothermia

Defined: Exposure tocold such that body tem-perature falls signifi-cantly.


Visual AssessmentHistory of exposure to cold. May be seen in homeless persons.Lethargy and unconsciousnessBradycardia, bradypnea

Bedside (Patient Contact) AssessmentBody temperature less than 36 deg C


Special Assessments

Decision Making

Oxygen via a heated aerosol at 40 to 100%

Keep resuscitation efforts going until body temperature is normal.

Mechanically ventilate as needed.

Keep in mind that blood gas values may be altered because of the difference in blood tem-perature and analyzed temperature. Watch out of oxygen (PaO2). In cold, uncorrectedblood, PaO2 may appear higher than it actually is.

What to expectNot very common. However

when seen, may be seen in con-junction with other problems such

as AIDS, or tuberculosis.

Burn Trauma/CO Poisoning

Defined: Results fromdirect exposure to fireand or smoke. Directlythreatens airway andoxygen carrying capacityof the blood.


Visual AssessmentDiagnosis is based largely on historyexposure to fire or smoke. Often occurs in

occupational related cases (fire fighter)Visible burns about the body and faceSinged nasal and or eyebrow hairsCherry-red color of face with CO poisoningPatient is often confused or unresponsiveStridor, hoarseness

Bedside (Patient Contact) AssessmentBreath soundswheezing, rhonchi, rales

Basic Laboratory AssessmentABGsinitially decreased PaCO2, normal PaO2, decreased saturation. Latter may

develop into respiratory acidosisChest X-raymay be clear at first, but later may show pulmonary edema and

markedly decreased lung compliance

Special AssessmentsCOHb 20% or more

Decision Making

Protect airway by establishing an artificial airway immediately. Particularly if there is respi-ratory distress and there are burns about the face.

For CO poisoningstart 100% oxygen immediately even if only suspect itdo not waitfor COHb results

Continue oxygen therapy until COHb level is below 10%.may use hyperbaric medicine ifofferedoften will not be offered.

Practice Reverse isolation (protect the patient from staff)

Mechanically ventilate as needed.

What to expect

Fairly common case on the test.Remember to focus on the airwayand on oxygen carrying capacityof the blood. Remember to em-ploy isolation techniques. Other-wise, provide general respiratorytherapy.

Diabetes

Defined: Condition re-lated to failure of the re-nal system resulting inthe inability to dispose ofCO2. Respiratory resultis often respiratory keto-acidosis


Visual AssessmentHistory of diabetesLethargy, confusion, unresponsivenessRespiratory rate and patternsignificant in depth and rate with an irregular

rhythm (Kussmauls)

Bedside (Patient Contact) AssessmentPedal Edema

Basic Laboratory AssessmentABGsProfound metabolic acidosisUrine output is markedly decreased (less than 20 ml per hour)

Special AssessmentsBlood glucose - > 160 mg (Normal 80-120 mg)

Decision Making

Must watch for ventilatory failure from prolonged ventilatory effort and fatigue.

Administer electrolytes (K+, Na+, HCO3-, Cl-) as needed.

Provide fluid as needed.

Correct ketoacidosis.

What to expectMay be tempted by profoundly

acidodic pH. Only determinerespiratory failure through theCO2, or a sudden decrease in

ventilatory volumes and breathingrate.

AIDS

Defined: Disease of theimmune system com-monly resulting in pneu-mocystis carinii, a type ofpneumonia


Visual AssessmentPrevious history of HIV positive test resultsEmaciation, unexplained weight-loss, diarrhea, low-grade fevers, night sweats,Commonly homosexual activity or drug usage is admitted

Bedside (Patient Contact) Assessment


Special AssessmentsPositive HTLV IIIELISA test positive for HIVBronchoscopyfrom lung washings or biopsy may show pneumocystis carinii

Decision Making

Exercise Universal Precautions

Aerosolized Pentamadineusually done monthly

When administering Pentamadine, use one-way valves and filters.

What to expect

Increasing in frequency on theexam. Sometimes is combinedwith tuberculosis, hypothermia,and others. Suspect them all.

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Copyright 2009 LindseyJones, LLC. All Rights reserved. The enclosed material is intended to facilitate preparation for theassociated credentialing exam. The information is not intended to direct healthcare practitioners on methods of practice.

Pathology Review

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