Thoracic/Respiratory

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
• Disposition
  • Admit patients who continue to be tachypnic or hypoxic despite treatment (floor, observation, or ICU depending on severity).
  • Patients who respond well to treatment can be discharged after a brief observation to ensure stability.

Pearls

• Be aggressive early in the management of asthma. Consider the use of epinephrine, similar to how you would use it with anaphylaxis.
• Due to it bronchodilatory effects, ketamine is the induction agent of choice for intubating asthmatics. 

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 
• Disposition
  • Discharge is appropriate if patient is stable and the source of the effusion is known and being treated. Should have close follow-up.
  • Admit patients with unknown sources or empyema. ICU is required for hemodynamically unstable.

Pearls

• In general, bilateral effusions tend to be from a transudative process (ex. CHF, cirrhosis) Unilateral effusions tend to be from an exudative process (ex. Infection, cancer, pancreatitis, etc.). 
• Ultrasound is a useful adjunct for both identifying pleural effusions and reducing the risk of complications during thoracentesis.

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)
• Disposition
  • Patients < 65 years old who appear well and have access to PCP follow-up within 72 hours can be safely discharged.
  • Admit anybody who doesn’t fit the above criteria. ICU if hemodynamically unstable.

Pearls

• The CURB-65 and the Pneumonia Severity Index are both available clinical scoring systems that can aid with disposition decisions.
• Always consider pneumonia in patients presenting with suspected exacerbation of underlying diseases (ex. Asthma, COPD, CHF)

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
• Disposition
  • Patients with resolution from spontaneous pneumothorax following treatment may be discharged with follow-up in 24-48 hours
  • Admit patients with tension pneumothorax or those requiring a chest tube.

Pearls

• Stardard IV angiocatheters are too short to adequately penetrate the pleural cavity, especially in larger framed individuals. Use pneumothorax specific catheters when possible. 
• JVD, hypotension, and tracheal deviation are late signs of tension pneumothorax. Do not wait for these signs to initiate treatment. 

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. 
• Disposition
  • Most patients with PE will be admitted. ICU if high risk for hemodynamic collapse.
  • Patients who are low risk and do not have right heart strain may be considered for discharge on anticoagulation and close follow-up.

Pearls

• EKG findings (ex. tachycardia, new T wave inversions, rightward axis) cannot definitively rule in/rule out pulmonary embolism, but may help push you to search for it. 
• A V/Q study is a reasonable alternative for pregnant patients, but tends to take longer and is less valuable in determining alternative etiologies.

Deep Dive

• Pulmonary Embolism (EM Cases)