situation review

8/2/2019 Situation Review

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Situation Review

Lindsey Jones


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General Assessment

Many times, during the clinical simulations, you will be asked to perform an assessment. TheNBRCs label for this is Information Gathering.

The list of options, from which you may choose, should NOT be looked at in multiple choicemanner. Not only are you to select those answers that are correct, but you should do so in theright order. Of all the options offered, each falls into one of four categories.

Visual Assessment (Stage I) Any assessment that you can do quickly by just glancing at the patient, a monitor, or thepatients record should be done first. Visual assessment items include:

General appearanceColor

Medical historyHeart rate (exception to the rule)

Bedside (Patient contact) assessment (Stage II) This includes all things that relate to the respiratory status of the patient and can bedone quickly and usually without cost or too much effort from the patient. Bedsideassessment items include:

Breath soundsPalpation of the chest or tracheaExamination of the upper airwayBlood pressure

Vital capacity measurement

Laboratory assessments (Stage III) This involves any test requiring laboratory analysis and/or interpretation. Or, it may require special equipment or technicians to perform. Laboratory assessments usually have a cost associated with them. These assessment items must relate to the respiratory status of the patient. Examples of laboratory assessments include:

Arterial blood gas analysisChest X-rayCBCUrinalysisPulmonary function screening (FEV1, pre and post bronchodilator studies)Serum electrolytesECGBilirubin level


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General Assessment (contd)

Special tests and assessments (Stage IV) Special tests are done when you suspect specific problems or diseases. They are often

costly and/or require significant time for interpretation. Or, it may be a special testbecause it relates only to one thing. Very often, this test is used for diagnosis. Picking incorrect special assessments will usually result in significant negative points.

Special tests and assessment should only be done if it relates!

Examples of special tests and assessments include:

CAT scan of the headComplete pulmonary function testing (DLCO, Nitrogen washout)Tensilon testBronchogramSweat chloride testMantoux testPulmonary angiogramLung perfusion scanNeck X-ray

Amniocentesis Acid-fast sputum stain

Special considerations

If you do not know what it is, DONT PICK IT

Recognize the difference between a test and the record of atest

Example AmniocentesisSpecial test, costly

Vs. Amniocentesis resultsalready done, just look at the results

Pulse and medical records are stage I


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General Assessment (contd)

Order Counts !

DO not advance to the next stage if the current stage reveals an emergency !Example: In the visual assessment (stage 1) you find:

General appearancept is cold, blue, stiff, and lying on the floor Heart rate is 0Respiratory rate 0

There is no need for breath sounds or any other stage 2 assessment.

You may get through stage 1 assessment but find it is anemergency in stage 2. If so, do not start doing laboratory

assessments (stage 3)

If you think youre clear to advance to the next stage of as-

sessment, pick everything in that stage.

Example: You find ABGs are very bad, patient needs a ventilator

Go ahead and get an x-ray if appropriate. Dont leave thescene at that point.

Stage I and II are usually combined


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Ventilator: Initial Adult Settings

There are five areas that must be addressed when initially placing a patient on a ventilator. Inorder of importance and priority, they are:

Rate Always between 8 and 12Immediately weed out all options that do not have rates between 8 and 12.

Tidal volume 8 - 12 mL/kg Calculate the range of appropriate tidal volumeImmediately discount every option that shows a tidal volume not in that range

OxygenIf it is an emergency, then FIO2 is 1.0Otherwise, the patient should be put on EXACTLY what they were on previously.If there is no record of previous FIO2 then use the adult therapeutic range of 40 to60%. Remember that oxygen is drug. So, if 40% and 55% is offered, then choose thelower.

PEEP Therapeutic PEEP for an adult is 10 cm H20. That means that if PEEP is offeredat 2 to 5 cm H20, then it is OK to pick. Do not worry too much about whether it isindicated or not. Remember, however, that on initial set up, less PEEP is better thanmore.

ModeNotice that mode is last priority because ALL MODES ARE GOOD. However, on theNBRC exam, first choose SIMV if available. Next, choose ASSIST/CONTROL.Lastly, CONTROL MODE should be used.

Consider:

Initial ventilator settings are easy points. There are, however, a couple of things to watch for:1 You may be forced to choose less preferable settings because the physician disagrees.

Do not be alarmed. You are likely getting positive points anyway.

2 The formula for tidal volume is based upon ideal body weight. That means you need todetermine if the patient is obese. It is usually obvious. Ie (5 feet, weighing 250 lbs). If you have an obese patient, you may estimate their ideal body weight by the following:

MAN 5 ft starts at 100 lbs. Then add 6 to 7 lbs per inch over feetWOMAN5 ft starts at 100 lbs. Then add 4-6 lbs per inch over 5 feet


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Adult Ventilator Weaning

An implied objective, when we place someone on a ventilator, is to get them off. Thus, whenperforming general assessments of patients on a ventilator, we are always asking, are they ready to come off?.

There are many ways to wean a patient from the ventilator, most of which are acceptable to theNBRC. There are a lot of studies that show different and seemingly opposing methods to beequally effective. Most methods involve decremental changes in rate, pressure, oxygen, pressuresupport, etc.

Another tricky situation: you have a slightly high or even low PaCO2 and a very poor oxygena-tion. Since a slightly high PaCO2 (46 torr) or low PaCO2 is not really a problem with ventila-tion, address the profound hypoxemia first.

Acceptable methods:Cold cessationremove from the ventilator and monitorIMV/SIMVgradual decrease in rate, allowing patient to breathe spontaneously Pressure support ventilationovercome dynamic compliance, gradual decrease.

More important that the method of weaning is the readiness to wean and your ability to distin-guish failure from success.

Readiness to wean:Readiness to wean is determined by the following (in order of importance)

VT >5 mL/kg VC > 10 mL/ghMIP > - 20 cm H2ORate 8 to 20 breaths per minuteRSBI < 100 (RR / Vt(L))

ABGs adequate oxygenation and ventilation (or same as before ventilator)Underlying condition needs to be resolved (if ventilatory related)

Weaning Failure

A patient fails if any of the above values fall below acceptable limits.Pulse > 20 bpm from baseline (prior to weaning)BP > 20 torr from baselinePaCO2 >10 torr from baselineRR >10 from baseline OR is > 30 breaths per minute

Also, weaning fails if there is a significant change in the patients status generally (ie confusion,lethargy, unresponsiveness).

If any of these are not acceptable, the pa-tient is NOT READY TO WEAN!


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Adult Ventilator Weaning (contd)

Successful Weaning

While there are no explicit expectations on what methods should be used for weaning, there aresome limitations on how far you need to go.

If SIMV rate 4 is accomplished, there is no need to decrease to 2No need to decrease FIO2 below 0.40No need to decrease PEEP below 5 cm H2O

Remember, cessation of mechanical ventilation does not mean extubation. One can stay on a ventilator on a heated aerosol and be extubated another day.


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Ventilator Troubleshooting

The effective use of mechanical ventilation involves may variablesthe machine itself, the cir-cuit, the patient, etc.

When you are placed in a situation involving a mechanical ventilator and a problem arises (asmanifested by ventilator alarm), you have the task to determine if it is the patient or the ma-chine. Therefore, you must understand those alarms and must know what to think about whenproblems arise. Most are common sense, but here are some guidelines.

High pressure alarm

Think about:

Patient Patient coughing, need suctioning?Patient resisting inspiration , need sedation?Pneumothorax, check for signsET tube cogged by sputum or herniated cuff?

Machine Accumulated water in the circuit?Pinched circuit?Recent change in alarm limits or settings?

Low pressure alarm

Think about:

Patient Chest tube leakagePatient inadvertently partially extubated (not always obvious)Cuff is under-inflated or deflated

Machine Circuit is disconnected from the patientCircuit has come apart or has a leak On some ventilators, flow rate may not be sufficient (pressure cycled machines)

Always begin MANUAL VENTILATION first, in response to any ven-tilator alarm. In some cases, you will not be given the option tomanually ventilate. In those cases, begin your troubleshootingSTART AT THE PATIENT first and work your way to the machine.


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Ventilator: Modifying Adult Settings

Making changes to ventilator settings will be a huge part of the clinical simulations. Almostevery patient ends up on one and will require some adjustment based on ABG results. Whenapproaching this, you should consider it in the same order of Vital functions, (ventilation thenoxygenation).

PaCO2 Make changes in rate when PaCO2 is out of range. Increase if PaCO2 is high, decreaseif low. If however, PaCO2 is only slightly out of range (ex PaCO2 33), consider making a change in tidal volume. Be on guard for this especially when dealing with a tidal

volume that is at the top of the range. The same is true if the PaCO2 is slightly high andthe tidal volume is in the lower part of the range. The best answer, if offered, would beto increase the tidal volume

Another way to make minor changes in PaCO2 is to add or subtract deadspace. If PaCO2 is slightly high, look for the option to add deadspace (usually 50 ml) to thecircuit and pick it before anything else.

PaO2 If PaO2 is low, then increase FIO2 by 10% or so. However, if FIO2 is already .55or .60, then you want to increase PEEP.

Do not be afraid of high PEEP, even if the patient is on 60% oxygen and thecurrent PEEP level is 20 cm H20. If hypoxic, then increase PEEP to 22 or 25. Theonly problem with increasing PEEP is a threat to hemodynamic values as manifestedby low CVP or CO. When you are not given such information, assume they are normalkeep increasing PEEP.

When over-oxygenation is occurring, FIRST LOWER FIO2 until at 0.6. Then, lowerPEEP.

Do not be too casual about letting patients PaO2 get too high. On the exam, it is aserious matter because oxygen is a drug. If PaO2 is 118 torr, for example, you willcertainly want to lower it.

Consider:

Sometimes you may be challenged by a high PaCO2 level and a low PaO2 at the same time. Re-member that ventilation comes before oxygenation and address the PaCO2 first.

Another tricky situation: you have a slightly high or even low PaCO2 and a very poor oxygena-tion. Since a slightly high PaCO2 (46 torr) or low PaCO2 is not really a problem with ventila-tion, address the profound hypoxemia first.


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Infant Ventilator Setup

Ventilator TypeInfant Ventilators are usually time cycled pressure limited.

Mode Always pick SIMV/IMV mode first

RateGreater than 20 breaths per minute

PressureGreater than 20 cm H2O

FIO2Same as previous. If there is not previous setting, then 30 to 60%If Emergency, then 100%. Most often, you have been manually resuscitating the infant, so you

will choose 100%.

PEEP0 to 2 cm H2O. Although you may advance to higher PEEP settings, (never go more than 8cm H2O) start at 0 to 2 cm H2O when initially beginning mechanical ventilation. ChangePEEP in increments of 1 if possible.

Also, if the infant was on CPAP, put the initial PEEP level and FIO2 at the same levels of the

CPAP settings.


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Adult Oxygen Therapy

There are only 3 levels of oxygen therapy on the simulations.

COPD level2428% Usually 1-2 lpm nasal cannula or a venturi mask

Adult Therapeutic level40-60% Usually 60% is not an option. Will more likely be 55%

Emergency level100% Any emergency for any patient, any age (including COPD)

The adult therapeutic level is important. If the situation is not an emergency, and you do nothave reason to suspect COPD, even the simplest cases should be put on 40-60% oxygen

Example: PneumoniaABG show PaO2 of 77 mm Hgplace on 40-60%

ABOVE 60%In cases where 60% is not enough to maintain good color or adequate PaO2, then em-

ploy CPAP or BIPAP. Do not go higher than 60% unless it becomes an emergency.


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Modifying Therapy

This is a very encompassing area that is impossible to cover every potential situation. TheNBRC will constantly be testing your ability to recognize the need to modify therapy. Perhapsthe best way to get this point across is list several examples.

Problem: Patient becomes short of breath when getting CPT with the head of bed downPossible actions: Stop the therapy, switch to other secretion mobilizing therapy like PEPtherapy or incentive spirometry.

Problem: Patients secretions remain thick in spite of significant hydration therapy withheated aerosolPossible actions: Give Mucomyst, try ultrasonic nebulization

Problem: Patient experiences PVC when suctioning for more than 10 secondsPossible actions: suction for only five seconds at a time.

Problem: Patient complains that it takes too much effort to take a breath off the IPPB ma-chine.Possible actions: increase sensitivity

Problem: patient experiences tachycardia after inhaled Albuterol treatmentsPossible action: switch medications

Problem : it is taking excessive amounts of pressure to mechanically ventilate a patient.Possible action: switch to pressure control ventilation, use reverse I:E ratio.the simplest cases should be put on 40-60% oxygen


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Airway Care

Since the airway it the key to ventilation, the first and most important vital function of life, you will be likely given situations involving the airway. You must be able to know when you need toestablish an artificial airway, know when the artificial airway is threatened, and recognize signsand symptoms of airway problems.

Establishing an artificial airway

Establish an airway when: The natural airway is threatened by current or potential inflammation as seen inburn trauma, upper airway surgery, and bacterial infection (acute epiglottitis).

The airway may be traumatized. Seen in diving accident victims or otheraccidents involving neck injury.

The patient is at risk for aspiration of gastric contents. This is seen in drug overdose or head trauma

To facilitate bronchial hygiene during extreme cases of fluid or sputumproduction through the lungs. Fulminating pulmonary edema is a goodexample.

The patient shows marked signs of ventilatory problems, such as sternalretractions, nasal flaring, supraventricular retractions, etc.

Procedural considerations

Use the head-tilt/chin lift in oral intubationHave tubes of various sizes on handHave all intubation equipment on hand (magil forceps for nasal intubation)If inflammation is present, consider having it performed in surgery.Use bronchoscopy if a complicated intubation is suspected (neck injury,

excessive inflammation). May use blind nasal intubation butbronchoscopy should be your first step.

The ET tube should be advanced 2 cm beyond the carina, OR 1 inch beyondthe carina

Proper placement of the ET tube should be done first auscultation of the chest

and visualization of chest movement. Then, a chest x-ray should beused.

Intubation with a bronchoscope is preferred above all other methodswhen complicated intubation is suspected.


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Airway Care (contd)

Maintaining an artificial airway

Use a suction catheter to ensure patency. When the tube is completely blocked (as determined by the inability to pass a suction

catheter or marked inspiratory effort), the action should be toREMOVE THE TUBE. Do not be afraid of this response. It is very oftenappropriate, especially in neonates.

Be on guard for problems with ET tube cuffs. The may herniatedeflate the cuff and replace the tube They may rupturepull the tube patient in distress, plan to replace if the

patient is OK and return volumes are appropriate

Repositioning the tube may be then answer if breath sounds are not bilateral, areheavily diminished or absent in one side. Distinguish this situation from apneumothorax by the patients conditionvery much worse if pneumothorax.


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Cardiac Arrhythmias

There are several situations on the clinical simulations that involve cardiac arrhythmias and theirtreatment. Cardiac arrhythmias may be associated with a specific disease process, but are oftenthe results of general cardiopulmonary compromise.

PVC (Premature ventricular contraction)Most often occurs when patient becomes hypoxic. It is not immediately life-threatening so it is NOT an emergency.

Primary treatment involves OXYGEN administrationSecondary treatment involves LIDOCAINE

If PVCs occur during specific therapy or medication administration, then you need toSTOP THERAPY.

Pulseless ventricular tachycardia This is a very deadly rhythm that constitutes an emergency.

Primary treatment is DEFIBRILLATION starting with 200 joules, then 300,then 360 joules.

Secondary attempts at treatment, if defibrillation is unsuccessful, is the use of medications including EPINEPHRINE, LIDOCAINE, BRETYLIUM.

Ventricular fibrillation This is also a deadly rhythm and constitutes an emergency. Generally, this should be

treated the SAME AS PULSELESS V-TACH. You may also want to correct metabolic acido-sis through bicarbonate administration. If a transition from V-Fib to V-tach occurs while youare with the patient, then you may do a PRECORDIAL THUMP.

Persistent v-tach or v-fibFollow a specific course of defibrillation and medication administrationChest compressionsintubationestablish IV access

Then:EpinephrineDefibrillate at 360 watt/secLidocaineDefibrillate at 360 watt/secLidocaineDefibrillate at 360 watt/secBretyliumDefibrillate at 360 watt/secMore BretyliumDefibrillate at 360 watt/sec

Asystole / Pulseless electrical activity (PEA) also called EMD This involves a complete cessation of electrical activity in the heart and or only the ces-

sation of contractions.Primary treatment is CARDIAC COMPRESSIONS and PACINGSecondary treatment is EPINEPHRINE, ATROPINE

NO DEFIBRILLATION with asystole !


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Conservationism

Conservation, with regard to the NBRC exam, relates to everything you do. In other words,you should be conservative when making choices.

Drugsbetter to give less, then more if needed

Pressurebetter to give less

Speedbetter if it takes less time

Costbetter if it cost less

Invasivenessbetter is less invasive

Subjectivenessbetter if the patient likes it better

Factsbetter than estimation

Effortbetter if it takes less effort

Personal intervention is better than a machine (technology)


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Bronchoconstriction

Unlike a real hospital setting, a breathing treatment does not cure everything. The type of medi-cation and used depends upon the nature of the problem.

Bronchoconstriction is typically manifested by wheezing. The solution is a bronchodilator.Bronchodilation can be done by IV, pill, or aerosolized bronchodilator.

Aerosolized Albuterol, Ipratropium bromide (Atrovent), Metaproternol, Bitolterol can be given via an aero-sol. Usually, it is done with a small volume nebulizer. The test may refer to it simply asAerosolilzed Albuterol, etc.

Intravenous/PillBackdoor bronchodilators include all Xanthine medications including, Aminophylline, Theo-phylline and others.

Subcutaneous1:1000 strength epinephrine may be give in extreme cases where repeated traditional bronchodi-lators are not working. Usually happens in cases such as Status Asthmaticus. It is acceptable todeliver three successive doses, 20 minutes apart.

Common Bronchodilators

Albuterol 0.5 mL Q4 hours Terbutaline 0.5 mL Q4 hoursBitolterol 1.25 mL QIDPirbuterol 2 puffs Q 4 6 hoursSalmeterol 2 puffs BIDMetaprotereno 0.3 mL Q4 hours

Theophylline (Aminophylline, IV) (Theo-Dur by pill)


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Emergency Response

Whatever the disease, whatever the problem, situations on the clinical simulations are all dealt with in the same manner. For example

If some one is cyanotic, whether it is because of pneumonia, tuberculosis or anything,treatment is oxygen therapy.

Consequently, you should think of the clinical simulations in term of the situation and less of the disease. That is not to say that the underlying disease is not important; for ultimately,youll want to solve the underlying problem to truly treat the patient. However, most of prob-lems in the clinical simulations relate to situations rather than disease

MANY situations and diseases, HOWEVER, are emergencies by definition. As such, the mustbe dealt with in a different manner.

Emergency Situations Any situation that threatens the four VITAL FUNCTIONS OF LIFE is an emergency. Thefunction that is at risk should be addressed first.

Cardiac arrestcompressions and medications Acutely inflamed airwayestablish an artificial airway Marked cyanosis100% oxygenLoss of blood pressuregive fluids, administer cardiac drugs

If several function are in jeopardy, then they should be addressed in order (ventilation, oxygena-tion, circulation, perfusion)

Not all emergency situations can be covered here, so you must think critically and always ask yourself, after an assessment or scene description, Is this an emergency? If so than deal withthe emergency first before anything else.

Note: If it is an emergency, always use 100% oxygen. There are no exceptions to this rule.

Emergency diseases While not all emergency situations can be considered here, there are some diseases that are always to be considered an emergency.

PneumothoraxPulmonary EmboliPulmonary EdemaCongestive heart failureCO poisoning

Any Trauma involving head, chest, neck, lungs, burnStatus Asthmaticus


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Associations

You will not find many pictures on the simulations. Thusly, everything is conveyed by words orphrases. Many of those words or phrases can be uniquely associated with a certain diseases orconditions.

For instance, if an X-ray is described as having a Batwing pattern, then the likely problem ispulmonary edema.

Provided in the next couple of pages is a list of descriptors that are commonly associated withspecific diseases or conditions. As you review the list, keep in mind that they are not all definitein their associations. For example, when you see that somewhat is experiencing tachycardia, youshould think that the patient is likely hypoxic and prepare to treat that hypoxemia with oxygen.However, tachycardia may be the results of a number of other problems.

The point is, the purposes of the list is to increase your critical thinking skills by helping youthink about what may be the problem and give you a starting point to begin your thinking. If a word or a phrase causes you to think the patient has a certain disease or condition, you shouldset out to gather data that proves or disproves your theory as you advance through each simula-tion case.


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Associations

Descriptor Association Action

Tachycardia Hypoxemia Give oxygen

Cold, clammy skin Myocardial infarction Give oxygen, do ECG

Suddenly short of breath Pulmonary embolism 100% oxygen, V/Q scan, anticoagulants

Sudden onset of tachypnea Pneumothorax 100% oxygen, chest x-ray, chest tubes if positive

Butterfly pattern on X-ray Resp Distress Syndrome(ARDS) or (IRDS)

Keep FIO2 low as possible, keep ventilatory pressuresdown

Reticulogranular pattern on X-ray Resp Distress Syndrome(ARDS) or (IRDS)

Keep FIO2 low as possible, keep ventilatory pressuresdown

Pitting edmea CHF Cardiac drugs, digitalis, digoxinMaintain good fluid balance (often diurese patient)

Cyanosis Hypoxemia Give oxygen

Pt confused, anxious Hypoxemia Give oxygen

Marked anything Usually an emergency Address it quickly

Severe anything Usually an emergency Address it quickly

Lethargic, sleepy, somnolent COPD O2 overdose Lower the oxygen

Stuporous, confused, inappropriateresponses

Drug overdose Protect airway (may intubate)Deliver Narcan if narcotic overdose)

Ventilation is at risk (unpredictable CNS depression)

Anxiety, nervous Hypoxemia Address the underlying problem, resolve the hypoxemia

Angry, irritable, or combative Electrolyte imbalance Fix it (delivery fluids, administer specific electrolytes)

Panic Severe asthma attack Give oxygen, bronchodilators

Orthopnea CHF Cardiac drugs, proper fluid maintenance (often diuretics)

General malaise Electrolyte imbalance Fix it

Digital clubbing COPD Low oxygen delivery

Diaphoresis Heart failure, fever, tuberculosis if night time

Address underlying problem

Night sweats Tuberculosis Treat the disease gener

Ashen or pallor color Anemia, acute blood loss Stop bleeding, give blood

Increased A-P diameter COPD Treat disease generally

Kussmauls breathing Metabolic acidosis, dia- betic, renal failure

Treat underlying problem

Apneustic breathing Brain trauma or tumor Treat the problem

Muscular hypertrophy COPD Treat the disease

Retractions Significant resp distressin infants

Support ventilation, administer oxygen


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Associations, Contd

Descriptor Association Action

Paradoxical chest movement Flail chest Ensure ventilation, watch for pneumothorax

Pulses paradoxus Status asthmaticus, severeair-trapping

Address the underlying problem

Flat to percussion Atelectasis Hyperinflation therapy

Dull to percussion Fluid-filled, pneumonia, pleural effusion

Address underlying problem

Hyperresonant to percussion Pneumothorax Chest tubes, chest X-ray

Course rales Rhonchi Suction patient if cannot cough, otherwise anything to mobilize secretions

Medium rales Needs anything to mobilize secretions, CPT, IPPB, PEPtherapy, etc

Fine rales CHF, pulmonary edema Diurese the patient, provide positive pressure ventilation,IPPB, cardiac drugs such as digitalis

Wheezing Bronchoconstriction Administer bronchodilator

Stridor Give racemic epi, intubate if marked or severe

Pleural friction rub Pulmonary infarction,TB, Lung CA

Treat underlying disease

Steeple sign (Lat neck X-ray) Croup Treat underlying disease

Thumb sign (Lat Neck X-ray) Acute Epiglottitis Treat underlying disease

Butterfly or batwing pattern (X-ray) Pulmonary edema Treat underlying disease

Fluffy infiltrates Pulmonary edema Treat underlying disease

Honeycomb pattern (X-ray) ARDS Treat underlying disease

Wedge-shape infiltrates (X-ray) Pulmonary embolus Treat underlying disease

Concave superior interface border Pleural effusion Treat underlying disease

Basilar infiltrates with meniscus Pleural effusion Treat underlying disease

Fattened T waves Hypokalmeia

Spiked T waves Hyperkalemia

Pink frothy sputum Pulmonary edema Treat underlying disease

Purulent sputum Chronic bronchitis Treat underlying disease

3-layer sputum Bronchiectasis Treat underlying disease

Tree in Winter pattern Bronchiectasis Treat underlying disease

Weakness in legs (lower extremities) Guillain-Barre Treat underlying disease

Drooping eyelids (Ptosis), doublevision (Diplopia), dysphagia

Myasthenia Gravis Treat underlying disease


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