2/16/2019

Non-Cardiac Chest

Therese Mead, DO, RDMS, FACEP Associate Program Director Central Michigan University EM Residency

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1 2/16/2019

A 82 year old female awoke with lip swelling 1 hour ago. On arrival to the ED, she is awake, alert, able to speak and Which part of the body can be affected by angioedema? complains of a slight pressure in her throat.

A. Lips BP: 220/110, HR 55, RR 22, T 36 C and SPO2 is 98% on room air. B. Extremities C. Genitalia On physical examination, the patient is sitting upright, slightly D. Tongue anxious, with lip swelling, neck edema, and tongue slightly E. All of the Above protruding.

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Angioedema Clinical Presentation

Which part of the body can be affected by angioedema?

A. Lips B. Extremities The lips, face, tongue, neck, extremities and/or genitalia can all be affected by angioedema C. Genitalia D. Tongue E. All of the Above

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Angioedema Pathophysiology

True or False: Angioedema is always an IgE mediated True or False: Angioedema is always an IgE mediated allergic reaction to a stimulus allergic reaction to a stimulus Angioedema is not always an IgE mediated allergic reaction to a stimulus

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Angioedema Clinical Presentation This patient’s presentation is consistent with which of these This patient’s presentation is consistent with which of these conditions? conditions? The etiologies of angioedema (a symptom), include:

A. Hereditary Angioedema (HAE) A. Hereditary Angioedema (HAE) ✓Hereditary Angioedema (HAE) B. Acquired C1 Esterase Deficiency (ACID) B. Acquired C1 Esterase Deficiency (ACID) ✓Acquired C1 Esterase Deficiency (ACID) C. Allergic Reaction C. Allergic Reaction ✓Allergic Reaction D. ACE Inhibitor-associated angioedema D. ACE Inhibitor-associated angioedema ✓ACE Inhibitor-associated angioedema E. All of the above E. All of the above Additional patient history and physical examination will help narrow the differential dx

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Angioedema Clinical Presentation

Which of the following findings is not consistent with the Which of the following findings is not consistent with the presentation of Hereditary Angioedema (HAE)? presentation of Hereditary Angioedema (HAE)?

Patients with Hereditary Angioedema (HAE) present with angioedema A. Abdominal pain A. Abdominal pain and often a family history (but 25% are de novo mutations) B. Nausea, vomiting and diarrhea B. Nausea, vomiting and diarrhea C. Family history of HAE C. Family history of HAE Some typical findings of an IgE mediated response (especially D. Urticaria D. Urticaria urticaria) are typically absent.

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Angioedema Clinical Presentation The presence of itching and urticaria would suggest which The presence of itching and urticaria would suggest which diagnosis? diagnosis?

A. Hereditary Angioedema (HAE) A. Hereditary Angioedema (HAE) B. Acquired C1 Esterase Deficiency (ACID) B. Acquired C1 Esterase Deficiency (ACID) The presence of itching and urticaria suggest an allergic reaction. C. Allergic Reaction C. Allergic Reaction D. ACE Inhibitor-associated angioedema D. ACE Inhibitor-associated angioedema E. All of the above E. All of the above

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4 2/16/2019

The patient provides additional history. She has hypertension, diabetes The patient provides additional history. She has hypertension, diabetes Angioedema Management mellitus, 3 prior coronary stents and no personal or family history of mellitus, 3 prior coronary stents and no personal or family history of angioedema. Medications include glucophage, ramipril and a angioedema. Medications include glucophage, ramipril and a multivitamin. multivitamin. Fresh frozen plasma may be helpful in ACE Inhibitor associated angioedema. Which of the following is the most appropriate next step in Which of the following is the most appropriate next step in management? management? Epinephrine may precipitate an acute coronary syndrome in this A. Administer Epi 1:1000 0.3mg IM A. Administer Epi 1:1000 0.3mg IM elderly, severely hypertensive patient with known coronary artery B. Administer Epi 1:1000 0.5mg IM B. Administer Epi 1:1000 0.5mg IM disease C. Order 2 units of fresh frozen plasma C. Order 2 units of fresh frozen plasma D. Perform immediate cricothyroidotomy D. Perform immediate cricothyroidotomy

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Angioedema Management

Given the additional history, which medication is least likely to be Given the additional history, which medication is least likely to be effective in relieving this patient’s symptoms? effective in relieving this patient’s symptoms? ✓C1 esterase inhibitor [human] is indicated for HAE, not ACE A. 2 units of fresh frozen plasma A. 2 units of fresh frozen plasma inhibitor associated angioedema. B. Diphenhydramine 50mg IV B. Diphenhydramine 50mg IV C. Famotidine 20mg IV C. Famotidine 20mg IV ✓FFP, H1 and H2 blockers may be beneficial in ACE inhibitor associated angioedema. D. C1 esterase inhibitor [human] D. C1 esterase inhibitor [human]

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5 2/16/2019

Angioedema Management The patient just remembers that she actually ran out of her The patient just remembers that she actually ran out of her ramipril two years ago. Her husband tells you that her cousin ramipril two years ago. Her husband tells you that her cousin Joyce and daughter Cynthia had the “same thing happen to them Joyce and daughter Cynthia had the “same thing happen to them last year.” Appropriate laboratory tests might include last year.” Appropriate laboratory tests might include Given the absence of an ACE inhibitor, ACEI associated angioedema is impossible. A. CBC A. CBC Her family history suggests Hereditary Angioedema. C4 and C1 B. C2, C4, C1q, C1-inhibitor B. C2, C4, C1q, C1-inhibitor esterase inhibitors are useful in this diagnosis. In the US, the C1 C. Troponin C. Troponin esterase inhibitor function is insensitive (C4 will be low at D. Liver transaminases D. Liver transaminases baseline and during an attack)

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1 week later, one of your attending physicians is reviewing lab 1 week later, one of your attending physicians is reviewing lab References: results that returned after patient discharge. She notices that one results that returned after patient discharge. She notices that one of your patients had a C1 inhibitor and C4 that were “low” and of your patients had a C1 inhibitor and C4 that were “low” and US Hereditary Angioedema Association. Diagnosing HAE. wants to know what to do with this result. You tell her: wants to know what to do with this result. You tell her: http://www.haea.org/professionals/diagnosing-hae. Accessed online: 1/9/16. A. This rules out Hereditary Angioedema in your patient from A. This rules out Hereditary Angioedema in your patient from Tran TP and Muelleman RL. Allergy, Hypersensitivity, and Anaphylaxis. In: last week. Please notify the patient. last week. Please notify the patient. Marx JA, Hockberger RS, Walls RM. eds. Rosen’s Emergency Medicine – B. This rules in Hereditary Angioedema in your patient from last B. This is suggestive of Hereditary Angioedema in your Concepts and Clinical Practice. 7th ed. Philadelphia, PA: Elsevier/Saunders, week. Please notify the patient. patient from last week. Please notify the patient. 2010 C. I don’t really know why I drew that test. Just check physician C. I don’t really know why I drew that test. Just check physician aware. aware.

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6 2/16/2019

Asthma: A 15 year old female with history of asthma developed shortness Appropriate initial stabilization includes all of the following of breath 1 hour ago. On arrival to the ED, she is awake, alert, except: 1.8 million ED visits (2011) and appears mildly anxious. A. Nebulized albuterol solution 1.25 mg every 20-30 minute x 3 BP: 140/80, HR 110, RR 34, T 36 C and SPO2 is 89% on room doses air. 3,630 deaths (2013) B. Nebulized ipratropium 0.5mg every 20-30 minutes x 3 doses, mixed with albuterol solution On physical examination, the patient is sitting upright, slightly anxious, with tachypnea. Lung sounds are diminished with faint C. Oxygen therapy 219 deaths of children wheezing. (2013) D. Prednisone 40-60mg E. Theophylline 5mg/kg PO

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Asthma Management Appropriate initial stabilization includes all of the following While all of the below conditions limit airflow in asthma, ______except: may decrease the response to therapy by causing permanent ✓IV access for severe exacerbations structural changes. A. Nebulized albuterol solution 1.25 mg every 20-30 minute x 3 ✓Pulse oximetry doses ✓Maintain SaO2 >90% A. Bronchial constriction B. Nebulized ipratropium 0.5mg every 20-30 minutes x 3 doses, ✓Nebulized albuterol solution (short acting inhaled B2 agonist) B. Bronchial edema mixed with albuterol solution ✓Systemic corticosteroids for all moderate to severe attacks C. Mucous plugging C. Oxygen therapy ✓Ipratropium bromide may be added to first 3 albuterol treatments for severe exacerbations D. Airway remodeling D. Prednisone 40-60mg ✓Methylxanthines (theophylline) and Leukotriene modifiers E. All of the above E. Theophylline 5mg/kg PO (montelukast) not recommended in acute setting

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7 2/16/2019

Asthma Pathophysiology While all of the below conditions limit airflow in asthma, ______may decrease the response to therapy by causing permanent structural changes. • Bronchospasm True or False: Early Response • Edema A. Bronchial constriction • Airflow Obstruction Asthma is a chronic inflammatory condition B. Bronchial edema associated with bronchial hyper responsiveness C. Mucous plugging and some reversibility • Airway inflammation D. Airway remodeling Late Response • Airflow obstruction E. All of the above • Airway Hyper response

Adapted from Figure 71-3 Rosen Ch 71 p 890 43 44 45

Asthma Pathophysiology Asthma Management

True or False: ✓IV steroids are not more effective than PO Asthma is a chronic inflammatory condition steroids … unless the patient cannot tolerate associated with bronchial hyper responsiveness IV steroids are more effective than PO steroids oral intake and some reversibility ✓Give steroids promptly in severe attacks ✓Effects begin within hours (peak at 24 hours)

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8 2/16/2019

You have actively managed the patient for 1 hour. Her breath Asthma Clinical Presentation sounds are more diminished and pulse oximetry is 90%. Your primary nurse is asking if you want any “tests” ordered. You then order:

True or False: A. No additional testing at this time Wheezing does not correlate with disease B. Chest x-ray The absence of wheezing is reassuring severity and may be absent in a patient in extremis C. Arterial blood gas D. EKG E. Peak Expiratory Flow Rate F. B and E G. C and D

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You have actively managed the patient for 1 hour. Her breath sounds are more diminished and pulse oximetry is 90%. Your Asthma Management primary nurse is asking if you want any “tests” ordered. You then You have actively managed the patient for 1 hour. Her PEFR order: remains <40% predicted. She can still converse and is sipping on ✓When possible, PEFR or FEV1 should be measured in acute Rockstar. You should: exacerbations. % Patient’s personal best is most helpful A. No additional testing at this time A. Order magnesium sulfate 2 gram IVPB over 20 minutes B. Chest x-ray ✓ABGs are rarely clinically useful in this setting C. Arterial blood gas ✓Patients who do not respond to usual therapy have 15% B. Prepare to intubate incidence of radiographically identifiable pulmonary C. Administer montelukast 10mg PO D. EKG complications (pneumothorax, pneumomediastinum) D. Order salmeterol 1 puff inhaled E. Peak Expiratory Flow Rate ✓ECG is not routinely indicated unless the patient is older or E. Administer Epi 1:000 0.3mg subcutaneous F. B and E cardiovascular disease suspected G. C and D

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9 2/16/2019

Asthma Management You have actively managed the patient for 1 hour. Her PEFR Your attending physician asks which of the following is not a risk remains <40% predicted. She can still converse and is sipping a Rockstar. You should: factor for death from asthma? You should order magnesium sulfate 2 gram IVPB over 20 minutes to relax bronchial smooth muscle and dilate the airways A. Order magnesium sulfate 2 gram IVPB over 20 A. Cocaine use minutes B. Severe psychiatric disease ✓Subcutaneous adrenergics (epinephrine and terbutaline) do not B. Prepare to intubate C. Two or more hospitalizations for asthma in the past 1 year C. Administer montelukast 10mg PO have an advantage over aerosol but may be considered D. Use of >2 MDI short-acting B agonist canisters per month D. Order salmeterol 1 puff inhaled ✓There is no role for salmeterol or leukotriene inhibitors in the 2 acute setting E. Younger age at time of diagnosis E. Administer Epi 1:000 0.3mg subcutaneous

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Asthma Clinical Presentation Your attending physician asks which of the following is not a risk The patient made minimal improvement with magnesium sulfate. factor for death from asthma? Risk factors for death from asthma: Additional measures might include:

A. Cocaine use Prior Severe Exacerbation >2 MDI albuterol canisters Inner-cityresidence Cardiovascular disease A. Administer ketamine B. Severe psychiatric disease per month B. Place patient on CPAP or BIPAP 2+ hospitalizations in year Difficulty determining Severe psychosocial Chroniclung disease C. Two or more hospitalizations for asthma in the past 1 year asthma severity problems C. Request heliox 3+ ED visits in year Low socioeconomic status Cocaine and/orheroin use Psychiatricdisease D. Use of >2 MDI short-acting B2 agonist canisters per month D. Administer high flow oxygen E. Younger age at time of diagnosis E. All of the above

Adapted from Box 71-1 Rosen Ch 71 p. 893 58 59 60

10 2/16/2019

Asthma Management The patient made minimal improvement with magnesium sulfate. Additional measures might include: ✓Ketamine has bronchodilator The patient’s urine pregnancy test is positive. Her mother wants to effects (watch for increased know if any of the medications you gave her is going to seriously secretions and emergency harm the baby. You tell her: A. Administer ketamine reactions) B. Place patient on CPAP or BIPAP A. No, all of the medications were Category C or lower and the C. Request heliox ✓CPAP or BIPAP may improve risks of uncontrolled asthma to both mother and fetus are high D. Administer high flow oxygen oxygenation and reduce fatigue B. Oops. I wish I hadn’t given the steroids! E. All of the above ✓Heliox reduces airway resistance

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Asthma Management On your way to see another patient, you walk by the patient with asthma’s room. The patient is lying back in the bed and her mother The patient’s urine pregnancy test is positive. Her mother wants to Acute asthma should be aggressively treated to avoid hypoxia reports that she seems very sweaty. You have difficulty arousing the know if any of the medications you gave her is going to seriously (maternal and fetal) harm the baby. You tell her: patient. Next step in management should include:

A. No, all of the medications were Category C or lower and Maternal and fetal risk of uncontrolled asthma = high A. Reassurance to the parent and initiate plans for discharge home the risks of uncontrolled asthma to both mother and B. Order an ABG fetus are high If systemic corticosteroids used, continuous fetal monitoring is C. Prepare for intubation B. Oops. I wish I hadn’t given the steroids! recommended at delivery D. Request one more nebulized albuterol treatment E. Call the patient’s pediatrician to arrange for 24 hour observation

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On your way to see another patient, you walk by the patient with asthma’s room. The patient is lying back in the bed and her mother reports that she seems very sweaty. You have difficulty arousing the patient. Next step in management should include: Beware the now “calm” Beware the normal ABG A. Reassurance to the parent and initiate plans for discharge home and “relaxed” patient in a severe asthma B. Order an ABG with a severe asthma exacerbation C. Prepare for intubation exacerbation D. Request one more nebulized albuterol treatment E. Call the patient’s pediatrician to arrange for 24 hour observation

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Asthma Management

You are preparing to intubate. Which of the following agents will not only provide sedation but also bronchodilation? Coma and apnea are absolute indications for intubation in asthma A. Ketamine B. Etomidate Exhaustion, hypoxemia, altered mental status are indications for intubation C. Propofol D. Versed

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Asthma Management You have successfully intubated the patient. Which is important You have successfully intubated the patient. Which is important in ventilator management for this patient? in ventilator management for this patient?

Ketamine is the preferred RSI induction agent for asthma and may A. Provide adequate oxygenation A. Provide adequate oxygenation be used with muscle paralysis (rocuronium 1mg/kg or succinylcholine B. Use a low tidal volume 6-8ml/kg B. Use a low tidal volume 6-8ml/kg 1.5mg/kg) C. Use a low ventilation rate (<10 breaths/min) C. Use a low ventilation rate (<10 breaths/min) D. Use high inspiratory flow rates D. Use high inspiratory flow rates E. All of the above E. All of the above

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Asthma Management You had just started charting and are called to the patient’s room You had just started charting and are called to the patient’s room for cardiac arrest. You note PEA on the cardiac monitor. Next for cardiac arrest. You note PEA on the cardiac monitor. Next Adequate oxygenation and ventilation should be provided while steps in management include all of the following except: steps in management include all of the following except: minimizing elevated airway pressures, barotrauma and hypotension. A. Disconnect patient from vent A. Disconnect patient from vent B. Compress chest B. Compress chest ✓low tidal volume 6-8ml/kg Permissive C. Place bilateral tube thoracostomies C. Place bilateral tube thoracostomies ✓low ventilation rate (<10 breaths/min) D. Give a fluid bolus D. Give a fluid bolus ✓high inspiratory flow rates Hypercapnia E. Administer terbutaline E. Administer terbutaline

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Asthma Management The patient’s sister also has asthma and thinks you’re an amazing References: doctor so asks you how to use her Metered-Dose inhaler properly. You tell her: http://www.cdc.gov/asthma/most_recent_data.htm. Accessed on: Squeezing of the lateral chest may relieve breath stacking ✓Remove the cap from the MDI container 12/19/15 ✓Assemble the MDI and hold upright ✓Shake the canister In the setting of abruptly high airway pressures followed by http://www.cdc.gov/asthma/asthma_stats/default.htm. Accessed on: cardiac arrest, the patient may have tension pneumothorax ✓Place the mouthpiece loosely between the teeth 12/19/15. requiring tube thoracostomy ✓Exhale fully ✓Activate the inhaler at the beginning of a slow inhalation lasting 5-6 seconds Nowak RM and Tokarski GF. Asthma. In: Marx JA, Hockberger RS, ✓Hold breath 10 seconds Walls RM. eds. Rosen’s Emergency Medicine – Concepts and Clinical Practice. 7th ed. Philadelphia, PA: Elsevier/Saunders, 2010 ✓Wait 1 minute before reuse

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A 60 year old male presents with shortness of breath, cough productive of brown phlegm for the past 7 days. He complains of COPD/Emphysema an increase in sputum production. He has smoked 1 pack of cigarettes daily for 20 years. Does this patient meet criteria for an acute COPD exacerbation? Y/N BP: 180/90, HR 110, RR 34, T 37 C and SPO2 is 86% on room air.

On examination, he is thin and anxious. You note pursed lip breathing and use of accessory muscles

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COPD Management

Characteristics of a COPD exacerbation:

Does this patient meet criteria for an acute COPD exacerbation? Y/N ✓change in the patient’s baseline dyspnea, cough, or sputum What is the most significant risk factor for the development of COPD? ✓beyond day to day variations ✓abrupt in onset ✓may require change in medications

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COPD Pathophysiology COPD Pathophysiology

While the terms “blue bloater” and “pink puffer” are outdated, Cigarette smoking is the most significant risk factor for the Which typical COPD phenotype does this patient fit? these phenotypes can be useful to describe the predominant development of COPD. However, only a minority of smokers develop pathophysiology COPD A. “Blue Bloater” ~ Pink Puffer Blue Bloater airway obstruction + obliteration of pulmonary vasculature B. “Pink Puffer” chronic obstructive bronchitis predominates emphysema predominates chronic respiratory failure and cor pulmonale lung overinflation and increased AP diameter  patient is plethoric with peripheral edema, JVD patient is thin, anxious, self peeps poor gas exchange

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COPD Management Which of the statements regarding pulse oximetry in COPD is Which of the statements regarding pulse oximetry in COPD is most accurate? most accurate? The change in pulse oximetry from patient’s baseline is more important than absolute levels. A. The change in pulse oximetry from patient’s baseline is more A. The change in pulse oximetry from patient’s baseline important than absolute levels is more important than absolute levels Indications for admission for COPD are: B. Any pulse oximetry reading less than 88% requires admission B. Any pulse oximetry reading less than 88% requires admission ✓ significant worsening from baseline C. Patients with COPD should not be discharged unless pulse C. Patients with COPD should not be discharged unless pulse ✓ inadequate response to ED therapies oximetry is greater than 94% oximetry is greater than 94% ✓ significant comorbidities ✓ worsening hypoxia or hypercarbia from baseline ✓ insufficient home resources

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Initial ED management for this patient should include: Initial ED management for this patient should include: COPD Management

Beta agonists and anticholinergics are first line therapy for A. Nebulized albuterol solution 1.25 mg every 20-30 minute x 3 A. Nebulized albuterol solution 1.25 mg every 20-30 minute x 3 COPD exacerbation doses doses B. Nebulized ipratropium 0.5mg every 20-30 minutes x 3 doses, B. Nebulized ipratropium 0.5mg every 20-30 minutes x 3 doses, Corticosteroids lead to a decrease in relapse and dyspnea mixed with albuterol solution mixed with albuterol solution C. Solumedrol 125mg IV or Prednisone 60mg PO C. Solumedrol 125mg IV or Prednisone 60mg PO Antibiotics are recommended for: D. Consideration for antibiotic therapy due to increase in sputum D. Consideration for antibiotic therapy due to increase in sputum ✓increase in sputum purulence and increased dyspnea or sputum E. All of the above E. All of the above volume ✓for any COPD patient requiring ventilation (including non- invasive)

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COPD Management Routine Initial ED testing for this patient should include: Routine Initial ED testing for this patient should include: Initial ED testing for this patient should include:

A. Arterial Blood Gas A. Arterial Blood Gas ✓ chest radiograph to rule out pneumothorax and coexisting B. CBC B. CBC cardiac pathology C. Chest radiograph C. Chest radiograph ✓ sputum cultures have limited value unless you expect a D. Peak Expiratory Flow Measurement D. Peak Expiratory Flow Measurement superinfection E. Sputum for gram stain E. Sputum for gram stain ✓ ABGs are of limited value, especially if you do not know the patient’s baseline

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The patient would like to know why his symptoms worsen. You The patient would like to know why his symptoms worsen. You Despite oxygen therapy, beta agonists, corticosteroids, the patient educate him that possible causes of an acute COPD exacerbation educate him that possible causes of an acute COPD exacerbation has ongoing dyspnea with increased work of breathing. He is able include his ongoing smoking and: include his ongoing smoking and: to speak in short phrases and is not diaphoretic. The next most appropriate step in management includes: A. Infection (Viral or Bacterial) A. Infection (Viral or Bacterial) B. Pneumothorax B. Pneumothorax A. Non-invasive ventilation C. Pulmonary Embolism C. Pulmonary Embolism B. Non-rebreather at 15 LPM D. CHF D. CHF C. Venti Mask at 50% FIO2 E. All of the above E. All of the above D. Order an ABG E. Prepare for immediate rapid sequence intubation

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COPD Management COPD Pathophysiology Despite oxygen therapy, beta agonists, corticosteroids, the patient has ongoing dyspnea with increased work of breathing. He is Non-invasive ventilation can be very effective in avoiding Additional possible etiologies of a COPD exacerbation include: alert, able to speak in short phrases and is not diaphoretic. The intubation, increasing pH and lowering PCO2. next most appropriate step in management includes: ✓atelectasis Contraindications for non-invasive ventilation include: ✓pneumonia ✓ Respiratory arrest ✓pulmonary compression (obesity, ascites, pleural effusion, A. Non-invasive ventilation ✓ Cardiovascular instability gastric distension) B. Non-rebreather at 15 LPM ✓ Uncooperative patient ✓trauma C. Venti Mask at 50% FIO2 ✓ Upper airway obstruction ✓neuromuscular disorders ✓ High risk for aspiration D. Order an ABG ✓ Recent facial or gastroesophageal surgery ✓other chronic pulmonary diseases E. Prepare for immediate rapid sequence intubation ✓ Facial trauma ✓noncompliance ✓ Non fitting mask

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COPD Clinical Presentation You have access to the patient’s most recent PFT in the electronic You have access to the patient’s most recent PFT in the electronic health record. You notice that the patient’s FEV1/FVC 60% health record. You notice that the patient’s FEV1/FVC 60% Stage Characteristics predicted and the FEV1 was 25% predicted. You inform the predicted and the FEV1 was 25% predicted. You inform the 0: At Risk Chroniccough and sputum patient that he has/is: patient that he has/is: Normal Spirometry I: Mild COPD FEV1/FVC <70% A. At risk for COPD A. At risk for COPD FEV1 >80% predicted II: Moderate COPD FEV1/FVC <70% B. Mild COPD B. Mild COPD FEV1 30-80% predicted C. Moderate COPD C. Moderate COPD III: Severe COPD FEV1/FVC <70% D. Severe COPD D. Severe COPD FEV1 <30% predicted

Adapted from Table 73-1 Rosen 7th Ed 106 107 108

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References

Swadron SS and Mandavia DP. Chronic obstructive pulmonary disease. In: Marx JA, Hockberger RS, Walls RM. eds. Rosen’s The patient wants to know what he can do to avoid meeting you The 2 interventions that alter the progression of COPD and reduce Emergency Medicine – Concepts and Clinical Practice. 7th ed. again. The 2 interventions that alter the progression of COPD and mortality are: smoking cessation and oxygen therapy. Philadelphia, PA: Elsevier/Saunders, 2010 reduce mortality are: ______and ______

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Pulmonary Emboli

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19 2/16/2019

A 59 year old female presents with cough and congestion. She was seen earlier at the local health clinic, complained of chest discomfort and was sent to your ED for evaluation. History includes a “mental disorder.” She takes no current medications. She has no recent travel or surgery. True or False: Applying the PERC Rule to this patient, pulmonary BP: 140/30, HR 90, RR 20, T 36 C and SPO2 is 96% on room air. embolism can be ruled out.

On examination, she is thin and anxious, wearing a sparkly pink tiara. Lung sounds are clear and there is no peripheral edema or calf tenderness.

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PE Clinical Presentation

✓The PERC Rule risk stratifies (<2%) but does not “rule out” PE The overall 30 day mortality rate for ED patients with PE is:

✓Clinician must have a low suspicion for PE and the patient A. 5% True or False: Applying the PERC Rule to this patient, pulmonary must fulfill all of the 8 criteria embolism can be ruled out. 1) Age <50 B. 10% 2) Pulse ox > 94% on room air C. 15% 3) HR <100 bpm D. 20% 4) No prior venous thromboembolism E. 25% 5) No recent major surgery or trauma 6) No hemopytysis 7) No estrogen use 8) No unilateral leg swelling

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PE Epidemiology

The overall 30 day mortality rate for ED patients with PE is: The most common symptom of PE is: A. 5% B. 10% The overall 30 day mortality rate for ED patients with PE is A. dyspnea C. 15% approximately 10% B. chest pain D. 20% C. palpitations E. 25%

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PE Clinical Presentation Initial ED testing for this patient should include: The most common symptom of PE is: A. EKG ~90% of patients with PE have some sensation of dyspnea B. Chest radiograph A. dyspnea ~70% of patients with PE have chest pain C. D-dimer B. chest pain ~50% of patients with PE have tachycardia D. CT Angiogram of the chest C. palpitations E. A, B and C F. A, B and D

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PE Management PE Clinical Presentation Initial ED testing for this patient should include: EKG findings associated with PE include: ✓ S1 Q3 T3 A. EKG ✓ Tachycardia B. Chest radiograph ✓ RBBB pattern C. D-dimer ✓ Inverted T waves in V1-V4 D. CT Angiogram of the chest ✓ P pulmonale E. A, B and C F. A, B and D Chest radiograph findings associated with PE include: ✓ Hampton’s Hump and Westermark Sign

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PE Clinical Presentation Well’s PE Criteria The patient’s d-dimer is 521 ng/ml. Creatinine is 1. Clinical Factor Points Based on the prior algorithm, you decide to order: Clinical DVT 3 PE as likely or more likely 3 Immobilization >3 days or surgery in past 4 wks 1.5 A. CT Angiogram of the chest Previous DVT or PE 1.5 B. No additional testing required Heart rate > 100 bpm 1 C. V/Q Scan Active malignancy 1 Hemoptysis 1 < 2 = low risk / 2-6 = moderate risk / > 6 = high risk

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22 2/16/2019

PE Management The CTA of the chest reveals extensive bilateral PE. Next The patient’s d-dimer is 521 ng/ml. Creatinine is 1. step in management includes: Based on the prior algorithm, you decide to order: A. Heparin 20 u/kg IV bolus then 12 u/kg/hr infusion In the non-pregnant patient with normal renal function, CT A. CT Angiogram of the chest angiogram is currently the test of choice for PE. B. Heparin 40 u/kg IV bolus then 20 u/kg/hr infusion B. No additional testing required C. Heparin 60 u/kg IV bolus then 30 u/kg/hr infusion C. V/Q Scan D. Heparin 80 u/kg IV bolus then 18 u/kg/hr infusion

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PE Management The CTA of the chest reveals extensive bilateral PE. Next step in management includes: The patient’s blood pressure decreases to 70/50. Additional immediate management should include: Heparin dosing for pulmonary embolism is: A. Heparin 20 u/kg IV bolus then 12 u/kg/hr infusion Load 80 units/kg IV, then initiate infusion at 18 units/kg/hr A. Alteplase 100mg IV over 2 hours B. Heparin 40 u/kg IV bolus then 20 u/kg/hr infusion B. Discontinue heparin therapy C. Heparin 60 u/kg IV bolus then 30 u/kg/hr infusion C. Cautious IV fluid resuscitation D. Heparin 80 u/kg IV bolus then 18 u/kg/hr Enoxaparin dosing for pulmonary embolism is: D. All of the above infusion 1mg/kg subcutaneous every 12 hours E. A and C

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PE Management References The patient’s blood pressure decreases to 70/50. Additional immediate management should include: http://emcrit.org/misc/aha-pulmonary-embolism-guidelines-2011. A. Alteplase 100mg IV over 2 hours Accessed: 12/19/15. B. Discontinue heparin therapy C. Cautious IV fluid resuscitation Kline JA and Runyon MS. Pulmonary embolism and deep vein D. All of the above thrombosis. In: Marx JA, Hockberger RS, Walls RM. eds. Rosen’s Emergency Medicine – Concepts and Clinical Practice. 7th ed. E. A and C Philadelphia, PA: Elsevier/Saunders, 2010

http://emcrit.org/misc/a ha-p ulmo nary-e mbo lism-g uide line s-20 11/

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… and that does it for

Non-Cardiac Chest

best of luck on the exam!

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