Pulmonary

Rapid Review

• Background
  • Diffuse airway inflammation characterized by bronchial hyperresponsiveness and reversible airflow obstruction.
  • Acute exacerbations can be caused by viral infections, allergens, tobacco, or emotional factors
• Signs/Symptoms
  • Dyspnea, cough, chest tightness. May present in respiratory failure.
  • (+) expiratory wheezing, (+) tripod positioning
• Diagnosis
  • Clinical diagnosis in emergency setting
  • Formal diagnosis made with spirometry
• Treatment
  • Nebulizers (albuterol/ipratropium), steroids, +/- magnesium, +/- epinephrine.
  • May require NIPPV or intubation

Pearls

Deep Dive

• Asthma (First 10 EM)

Rapid Review

• Background
  • Accumulation of excess fluid between the pleural space outside of the lungs.
  • May be transudative (due to fluid shifts) or exudative (due to infection, malignancy, etc.)
• Signs/Symptoms
  • Dyspnea, pain with inspiration
  • (+) decreased breath sounds, (+) decreased tactile fremitus, (+) dullness to percussion
• Diagnosis
  • CXR (shows blunting of costophrenic angle). Chest CT/US can also be used.
  • Thoracentesis is the gold standard. Light criteria used to differentiate transudative vs exudative effusion.
• Treatment
  • Thoracentesis or tube thoracostomy (depending on size and etiology)
  • Diuresis helpful if due to CHF 

Pearls

Deep Dive

• ED evaluation and management of pleural effusion: One size doesn’t fit all (emDOCs)

Rapid Review

• Background
  • Acute inflammation of the lungs caused by bacterial infection (typically S. pneumonia)
• Signs/Symptoms
  • Symptoms: Fever/chills, cough, dyspnea, rigors, pleuritic chest pain
  • Signs: Rust-colored sputum, tachycardia, rales/rhonchi
• Diagnosis
  • Clinical findings, (+/-) CXR
• Treatment
  • Antibiotics
    • Outpatient (doxycycline or azithromycin)
    • Inpatient (Ceftriaxone + azithromycin or fluoroquinolone)

Pearls

Deep Dive

• Pneumonia (SAEM)

Rapid Review

• Background
  • Accumulation of free air in the pleural space, causing partial or complete collapse of the lung.
  • Can be spontaneous (blebs, COPD, TB), iatrogenic (central line, thoracentesis), or traumatic (blunt/penetrating trauma)
• Signs/Symptoms
  • Symptoms: dyspnea, ipsilateral chest pain
  • Signs: (+) hyperresonance, (+) diminished breath sounds, (+) decreased tactile fremitus
• Diagnosis
  • CXR (absent lung markings along periphery)
• Treatment
  • Small pneumothorax (<15%) can be observed
  • Large pneumothorax (>15%) require thoracostomy

Pearls

Deep Dive

• Pneumothorax (emDOCs)

Rapid Review

• Background
  • Occlusion of pulmonary arteries by thrombi that typically originate from the lower extremities or pelvis
• Signs/Symptoms
  • Symptoms: Dyspnea (most common), pleuritic chest pain, syncope
  • Signs: (+) tachypnea, (+) tachycardia, (+) hypotension
• Diagnosis
  • CT PE is the gold standard
  • CXR may show “westermark sign” or “Hampton hump”
• Treatment
  • O2, anticoagulation (heparin, LMWH), hemodynamic support (fluids, pressors)
  • Thrombolytics for unstable patients. 

Pearls

Deep Dive

• Pulmonary Embolism (EM Cases)