Pathology Review PDF

LindseyJones
Pathology Review
Emphysema
Defined: Abnormal condition of the alveoli resulting destruction and loss

of elasticity.
Information Gathering
Visual Assessment
Cyanosis
Barrel chest
Accessory muscle use
Digital clubbing of the nail beds
Significant history of smoking and/or occupational exposure to smoke or other
pulmonary irritant
Bedside (Patient Contact) Assessment
Dyspnea
Basic Laboratory Assessment
Chest 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 Assessments
PFTflows are decreased especially middle sized airways (FEF 25-75%) and FEV1
What to expect
You will usually be tempted to
utilize high FIO2 because of the
severity of the hypoxemia. You
may also be tested with an emergency, the only time it is appropriate to use 100% oxygen on a
chronically obstructed patient.
There are usually two obstructive
simulations on the exam and they
are not extremely challenging.
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
Chronic Bronchitis
Visual Assessment
Productive cough, purulent sputum production
Exposure to pulmonary irritants, like history of smoking
Frequent infections
Defined: Condition where

the patient has a productive cough 25% of the
year for at least two consecutive years

Dyspnea
Chest 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 Assessments
PFTflows are decreased especially middle sized airways (FEF 25-75%) and
FEV1
What to expect
The most distinguishing characteristic is that the cough is productive and has been so for a good
portion of the year.
Decision Making
Anything that promotes good pulmonary hygiene such as chest physiotherapy, hydration
therapy when sputum is thick.
Fluid therapy if dehydrated.
Oxygen therapy for hypoxemia
Aerosolized bronchodilator therapy
Bronchiectasis
Defined: Abnormal condition where the bronchi

secrete large volumes of
pus during abnormal dilation
Visual Assessment
Productive cough, often with blood
Digital clubbing of the nail beds
Significant history if infections (recurrent)
Dyspnea
Chest X-raygenerally normal
Sputum culturegram negative bacteria
Special Assessments
Bronchogram is the primary test. Characterized as a tree in winter pattern
What to expect
Central to this is the Bronchogram
diagnostic test. Usually, you will
be told of the suspicion of Bronchiectasis.
Increasingly less common on the
test
Decision Making
Anything that promotes good pulmonary hygiene such as chest physiotherapy, hydration
therapy when sputum is thick.
Fluid therapy if dehydrated.
May have consider surgical intervention on some highly affected segments
Sleep Apnea Syndrome
Visual Assessment
Spouse 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 neck
Ability to fall asleep quickly
Defined: the cessation of

breathing during sleep.
Is usually obstructive in
nature but sometimes
can be central or a combination of the two
(mixed).

Dyspnea
Frequent urination during sleeping hours
ABGscould be normal or very slight respiratory acidosis and hypoxemia
Special Assessments
Polysomnography (Sleep study) - determines if obstructive or central
What to expect
This is still somewhat rare on the
test but it does show up.
Decision Making
If central, ventilatory stimulant medication may be used
If obstructive, use of CPAP or BiPAP is usually initially indicated with follow-up weight
loss or upper airway tissue removal through surgery.
Problem must be corrected immediately, so even if discharging, send devices home with
patient. In the absence of a titration study, initially ordered pressure should be 10 to 20 cm
H20.
It is important to remember to
avoid sending the patient home
without some sort of ventilatory
support.
Asthma
Defined: Abnormal constriction of the bronchials

resulting in sputum production and narrowed
airways.
Visual Assessment
Accessory muscle use
Tachycardia
Dyspnea
Wheezing
Congested cough
Wet, clammy skin
ABGspossible respiratory acidosis, could be hypoxic
Chest X-rayhyperinflation, scattered infiltrates, flattened diaphragms.
Special Assessments
PFTDecreased flows in FEV1 but diffusion is normal as manifested by DLCO
What to expect
When doing PFTs, always do a
pre and post bronchodilator study.
Consider effective if 15% or more
improvement is noted.
There are no significant traps in
this simulation except that the
patient may be unresponsive to
bronchodilators. In such a case,
you are dealing with Status Asthmaticus. Refer to that disease
Decision Making
Xanthine medication given IV (Aminophylline, etc)
Promote pulmonary hygiene
Status Asthmaticus
Visual Assessment
Historically non-responsive to bronchodilators. Patient will report the need to
take many bronchodilator treatments before feeling better.
Accessory muscle use and retractions
Dyspnea
Wheezing
Congested cough
Wet, clammy skin
Defined: Asthma that will

not respond to bronchodilation therapy, usually persists more than
24 hours.

Pulses paradoxus
ABGspossible respiratory acidosis when tiring, alkalosis at first due to anxiety,
could be hypoxic
Chest X-rayhyperinflation, scattered infiltrates, flattened diaphragms.
Special Assessments
What to expect
This simulation will challenge
your ability to recognize impending ventilatory failure. It is very
important that you treat it before
full ventilatory failure.
Decision Making
May deteriorate quickly, so if progression is shown, intubate, mechanically ventilate before full ventilatory failure.
Use subcutaneous epinephrine1 mL of 1:1000 strength. May need to give every 20
minutes for up to three consecutive doses
There is a frequent need to repeat

actions in this simulation which
will make you uncomfortable. Do
not be afraid to administer several
bronchodilators in succession.
The same is true of the subcutaneous epinephrine. If you give one
dose, you will likely have to give
another, and possibly another.
Continue if symptoms show no
signs of relief.
Myasthenia Gravis
Defined: Neuromuscular
abnormality where muscles experience paralysis
starting from the head
down to the feet including ventilatory muscles.
Visual Assessment
May have a history of Myasthenia Gravis if not the onset
Droopy facial muscles and eyelids (Ptosis)
Patient will describe slowly feeling weakness generally but feels better with rest.
Double vision (diplopia)
Dysphagia (difficulty swallowing)
Shrinking Vt, VC, MIP
Special Assessments
Tensilon Challenge Testpositive for Myasthenic crisis if improvement is noted
upon the administration of Tensilon
What to expect
This can be a very tricky simulation and it is likely that it will
show up on the exam. Especially
important is your use of Tensilon
to diagnose it and an understanding of the dangerous affects it
could have. Must always be prepared to assume ventilation.
Vt, VC, and MIP are key in monitoring this patient for degradation
in ventilatory status. Intubate
prior to full failure if possible.
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 anticholinesterase
with 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 mentioned drugs to provide maintenance.
Be totally prepared to intubate and mechanically ventilate prior to Tensilon challenge since it
could take out the respiratory drive
When VC falls off rapidly (especially if below 1.0 L) , then intubate and mechanically ventilate.
Drug Overdose
Visual Assessment
Historical drug use as told by previous admissions or family
Sometimes poor self-hygiene, emaciated
Defined: Potential loss of

ventilatory drive as a result of drug overdose
(usually a narcotic)

Look and act sleepy, difficult to arouse
Respiratory rate and pattern is low and/or shallow
ABGoften show pure respiratory acidosis and/or ventilatory failure
Special Assessments
What to expect
The most important part of this
simulation is the need for immediate intubation while recognizing
that there may not be a need to
mechanically ventilate until ventilatory status deteriorates.
Decision Making
#1 priority in this case is intubation to protect the airway, prevent aspiration of stomach
contents, 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.
Other Neuromuscular
Defined: Other neuromuscular diseases or

states include Poliomyelitis, Tetanus, Muscular
dystrophy, and even
botulism poisoning.
Visual Assessment
History of illness
Special Assessments
What to expect
If faced with these diseases, simply apply general respiratory
monitoring principles and facilitate ventilation when needed.
These are somewhat rare.
Decision Making
Monitor for ventilatory failure generally through Vt, VC, MIP and ABGs
Head Trauma
Visual Assessment
Sometimes trauma is visual with blood contusions on the head
History is trauma related, often automobile accident
Defined: Potential loss of

ventilatory drive as a result of drug overdose
(usually a narcotic)

Look and act sleepy, difficult to arouse
Respiratory rate and pattern is low and/or shallow and irregular
Pupillary response to light may be unequal or inadequate
Special Assessments
If intracranial pressure monitor is in place, may see ICP greater than 20
cm H2O
What to expect
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
Unique to this simulation is the

need to monitor ICP readings and
avoid anything that increases
MAP. You will likely need to
suction this patient to keep peak
pressures down but the very act of
doing so my elevate ICPs.
Chest Trauma
Defined: May any trauma

leading to fractured ribs
or flail chest
Visual Assessment
Circumstantial history (motor vehicle accident, etc)
Respiratory rate and pattern is fast and shallow due to pain
May have obvious trauma (bruising) on chest wall
Sharp chest pain, especially at the top of each breath
Paradoxical chest movement if ribs are broken in two places (flail chest)
Pneumothorax is possible (see signs and symptoms of pneumothorax)
Chest x-raymay reveal broken ribs, usually isolated in same area
Special Assessments
What to expect
Decision Making
This case is usually easy to recognize. You may be tempted by

options that address the broken
ribs when, in fact, you simply
need to address ventilation.
Anything that encourages deep (adequate) breathing in spite of pain such as IPPB, incentive
spirometry, coughing.
Very commonly, this case will

lead to pneumothorax or partial
pneumothorax or hemothorax.
Mechanically support ventilation when it is evident ventilatory failure is impending. If possible do not wait until full ventilatory failure.
Watch for ventilatory fatigue and eventual ventilatory failure
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
Hemothorax/Pneumothorax
Visual Assessment
Rapid and shallow respirations
Defined: Loss of adherence of the lung to the

pleural wall causing the
space to be filled with air
or fluid (bloody).

Percussion: hyperresonant if pneumothorax, dull if hemothorax
Tracheal shift: to affected side if pneumothorax, away if tension pneumothorax
Severe dyspnea
Very diminished or absent breath sounds
Pulses paradoxes
Chest x-raydefinitiveshow hyperlucency, tracheal or mediastinal shift
Special Assessments
What to expect
Pneumothorax, hemothorax, tension pneumothorax occurs very
frequently on the exam
May include the troubleshooting
of chest tube drainage devices
Decision Making
Usual treatment is insertion of chest tubes
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
Thoracic Surgery
Defined: Can have variety of complications from

throacic surgery
Visual Assessment
Always monitoring chest tube drainage adequacy
Looking for potential complications:
Hypovolemic shock, low hemodynamic values including blood pressure
Subcutaneous emphysema
Elevated ventilatory pressures
Chest x-rayto confirm proper re-inflation of the lung and proper placement
of chest tubes
Special Assessments
What to expect
Your ability to deal with and troubleshoot chest tube maintenance is
tested in this simulation.
Sometimes this case is combined
with chest trauma.
Decision Making
Anything that promotes expansion of the lungs including incentive spirometry, IPPB, and
positive pressure mechanical ventilation
If a lobectomy or pneumonectomy, ventilatory volumes should set lower
Fluid therapy if volume is a problem (often is).
Neck/Spinal Injury
Visual Assessment
Historical relevance, some sort of accident such as diving, automobile.
Visible damage to the neck
Altered conscious level
Pulse must be palpated brachially or femorally
Defined: Any trauma

threatening the physical
structure of the neck.
Can include neck or spinal surgery.

Vt, VC, PEFR, and other ventilatory volumes may quickly deteriorate
Neck x-raywill show injury
Special Assessments
What to expect
Your knowledge of special intubation techniques is what is being
tested in this type of simulation.
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 and
care can be taken to avoid inflicting further damage.
Alternatively, a blind nasal intubation is acceptable.
Abdominal Surgery
Defined: Surgery of in
the abdominal area for
various reasons.
Visual Assessment
All general visual assessments
All general beside assessment including all vitals
Ventilatory volumes (VC, Vt, FEV1) compared to pre-surgery baselines
Special Assessments
What to expect
Abdominal surgery is usually a
very general, non-complicated
case involving preventative care
and follow up.
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.
Adult Respiratory Distress Syndrome
Visual Assessment
Record may show a variety of insults to the lung including massive surgery,
near drowning, inhalation of gasoline, hypothermia, and others.
Rapid respiratory rate
Cyanosis
Defined: A condition that

results in significantly
decrease lung compliance and consequent
profound hypoxemia

Decreased lung compliance as manifested by increased plateau pressures
(decreasing static compliance)
ABGspersistent 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 Assessments
All hemodynamic values could deteriorate when positive ventilatory pressures
become significant.
What to expect
ARDS can be a very disquieting
case to deal with. Usually persistent increases in PEEP are needed.
Do not be afraid to increase PEEP
significantly.
Decision Making
As positive pressure is required increasingly, negative effects may be seen. All should be
done to minimize the mean pressure being put on the pulmonary system, while trying to
balance the need to ventilate with higher pressures an utilize PEEP to maintain oxygenation.
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 including pressure control, high frequency, etc
Also, most often, cardiac output

or some other hemodynamic value
will fall indicating a need to decrease PEEP in spite of profound
hypoxemia.
Laryngectomy
Defined: Surgery done to

address or remove cancer of the larynx.
Visual Assessment
Surgical record : Surgery radical (entire larynx) or simple (cord removal)
Medical history will show cancer in upper airway
Signs of airway obstruction after surgery. Usually caused by blood within a few
hours after the surgery.
Special Assessments
What to expect
In this case, you are always looking for post-surgical complications like blood clots in the laryngeal tube. Often, you will have to
mechanically ventilate this patient
through the laryngectomy tube.
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 6
weeks.
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 temporary
laryngectomy tube is in place, you must intubate and/or ventilate through that tube !
Guillain-Barre Syndrome
Visual Assessment
Medical history or patient complaint of recent fluenza-type sickness.
Defined: An insidious
neuromuscular problem
involving muscle paralysis. Paralysis begins in
the lower extremities and
moves upward, including
the ventilatory muscles.

Complaint of sluggish lower extremities
ABGsimpending or current ventilatory failure.
Special Assessments
Spinal tapwill show increased protein in the spinal fluid
What to expect
Decision Making
Like most neuromuscular cases,

you will be tested in your ability
to recognize deterioration in ventilatory muscles. In this case, onset
can be slow, so dont jump-thegun and mechanically ventilate
too early. Only do so as VC falls
below 1.0 L.
Be primarily concerned with loss of ventilation, monitor ventilatory volumes (VC, Vt) and
MIP.
Otherwise, you will be manipulating the ventilator and possibly

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

Primary treatment will involve mechanical ventilation and letting the syndrome run its
course.
Shock

tissues oxygenation is in
jeopardy due to a sudden
decrease in blood flow.
Visual Assessment
Historical evidence of an event or massive trauma or hypothermia, etc
General appearancecold, clammy, dusky, cyanotic
Tachycardia, tachypnea
Hypotensive
Temperature may be below normal
Reduction in urine output
ABGshypoxemia and ventilatory failure
Special Assessments
Reduction in common hemodynamic values (CVP, PAP, PCWP) and cardiac output.
What to expect
Shock will test your ability to
recognize it and monitor the patient for ventilatory failure. Most
of the simulation is dealing with
typical ventilatory considerations
such as ventilator manipulation.
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). This
can be highly variable.
Heart Surgery
Defined: Any kind of surgery on the heart
Visual Assessment
Do well rounded assessment prior to surgery including vital signs, family history
of cardiac illness.
Preoperative assessments of breath sounds
Baseline data including basic spirometry of all types including FEV1/FVC and
pre and post bronchodilator studies
ABGspreoperative for baseline
Special Assessments
What to expect
This case is not too complicated.
You may feel hesitant to do CPR
on someone fresh out of surgery.
Just do it.
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 CPAP
with mask.
Be on the alert for cardiac arrestperform CPR without reservation or consideration of
the heart surgery.
Pulmonary Edema / CHF
Defined: Significant reduction in cardiac output.

Involvement of fluid
penetrating the alveolar
capillary membrane into
the lungs.
Visual Assessment
History of CHF or pulmonary hypertension
Tachypnea, tachycardia, anxiety
Cold, clammy, diaphoretic
Pink frothy secretions
Edema of fluids (especially pedal edema)
Pitting edema (+2, +3)
Breath sounds reveal fine, wet rales
ABGsventilatory failure with moderate to severe hypoxemia
Chest X-rayButterfly pattern, fluffy infiltrates
Special Assessments
Increased hemodynamic pressure (PCWP, PAP, CVP)
What to expect
Decision Making
This case may feel complicated

because it involves the heart and
hemodynamic values. It is usually
easily identified by pink frothy
secretions and butterfly pattern on
the chest X-ray.
Treat as an emergency !
You may need to make the distinction between pulmonary

edema caused by cardiac problems and that which is caused by
alveolar capillary membrane problems (ARDS). If it is cardiac,
then you must treat the heart.
Cardiac intatropic stimulating drugs such as digoxin, digitalis if increased PCWP and PAP
100% oxygen
Administer diuretic medication furosemide (Lasix)
Be prepared to treat ventilatory failure with mechanical ventilation
Myocardial Infarction/Arrhythmia
Visual Assessment
History of chest pain, radiating pain down the left arm
Family history of disease
Diaphoretic
History of nausea
Tachycardia
Defined: Ischemia to the

heart causing muscle
damage and potential
failure.

Cold and clammy to the touch
Dyspnea
ABGshypoxemia
ECG (EKG) - pronounced Q waves and S-T segment elevation
Special Assessments
Cardiac enzymes including CPK, LDH, SGOT are elevated
Decision Making
Not necessarily an emergency.
Oxygen at adult therapeutic level (40 to 60 %) upon suspicion or first presentation so signs
and/or symptoms
Treat arrhythmias
Bradycardia with Atropine or Isuprel
PVCs with lidocaine or oxygen
Pulseless ventricular tachycardia with defibrillation
Ventricular Fibrillation with defibrillation
Note: For Ventricular fibrillation, defibrillate at ascending watt/sec or joule settings
200 300 360 joules
Do not exceed 360 joules
Note: For Atrial fibrillation or flutter, do synchronized cardioversionstart at 50 joules
What to expect
Will likely need to treat arrhythmias with appropriate medication
and/or defibrillation
Pulmonary Emboli
Defined: Situation where

the pulmonary artery becomes obstructed and
dead-space ventilation
results. Sometimes
called deadspace disease.
Visual Assessment
History of recent major surgery or trauma (amputations, clotted massive bleeding
sights)
Complaint of chest pain and dyspnea
Elevated vitals including pulse, respirations, and blood pressure
Breath sounds - wheezing and medium rales
PECO2 (Capnography) decreasing PECO2 during normal PaCO2
ABGspersistent hypoxemia in spite of increasing FIO2
Special Assessments
V/Q scan will ventilation without adequate perfusion
What to expect
This case primarily involves recognizing the pulmonary emboli
and treating it with anticoagulation medications. You will likely
have to monitor clotting times,
PTT or PT.
Otherwise, involves general respiratory therapy.
Decision Making
Anticoagulation therapy with Heparin or Coumadin
Note: must monitor clotting tests
PTT for Heparin
PT for Coumadin
Mechanical ventilation as needed.
Therapeutic oxygen at 40 to 60%
Newborn Assessment
Defined: Involves delivery of an infant is complicated by various problems
Newborn Assessment
APGAR
Color
2 points
pink
1 point
0 points
pink body
blue or pale
blue extremities all over
Pulse
above 100
below 100
none
Reflex irritability
(Grimace)
cough or
sneeze
facial grimace
none
Activity
(flexion)
active
movement
some flexion
of limbs
limp or no
movement
Respiratory effort
strong cry
weak cry
no cry
History
If poor APGAR, may be pre-term, congenital heart problem, meconium
aspiration IRDS, transient tachypnea
Other helpful assessments
Gestational age
Weight
What to expect
Will commonly have to do an
APGAR score. You may have to
pick the 5 essential elements from
a list. Dont be tempted by any
tests other than APGAR criteria
unless they can be done by simply
looking at the infant.
Decision Making
Or, you may be given the elements and asked what you want to
do about it.
If APGAR Score is:

0 to 3
PERFORM CPR
4 to 6
Administer oxygen, place infant in warm, neutrally thermal

environment, generally stimulate the baby
7 to 10 Monitor normally
Meconium Aspiration
Defined: Infant born having meconium in ventilation spaces
Visual Assessment
History of meconium-colored amniotic fluid
Often with full-term infants
Infant may have meconium staining about the body
May demonstrate grunting, retractions, nasal flaring
Poor color (cyanosis)
APGAR score between 0 and 6
ABGshypoxemia with respiratory acidosis, metabolic acidosis or mixed
Chest X-rayBilateral densities and widespread atelectasis
Special Assessments
What to expect
This is a very common case on the
test. It is fairly straight-forward
and easily recognized. The key to
this is repeated suctioning and
clearing of the airway.
Decision Making
Remove the meconium from the airway. If possible, suction the baby as soon as the head
appears 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.
Sudden Infant Distress Syndrome
Visual Assessment
History of pre-term birth
Family genetic predisposition
Observed, irregular respirations, bradycardia may increase risk of SIDS
Defined: Sudden apnea

occurring in newborn infants as a results of an
immaturity central control of ventilation.

Cold air on infants face may induce apnea
Diminished 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 expect
Somewhat rare case on the test.
Nothing particularly challenging.
Infant Respiratory Distress Syndrome
Defined: Condition in infants where alveolus maturity is below normal.
Visual Assessment
History may show pre-term infant
Onset can be immediately after birth or within a few hours
General respiratory distress, ie grunting, nasal flaring, retractions
Cyanosis
APGAR score between 0 and 6
Chest-Xrayradiological description such as ground glass, honeycomb,
reticulogranular
ABGspersistent hypoxemia in spite of elevated FIO2
Special Assessments
L/S ratio2:1 or higher is normal. Less than that shows lung immaturity
What to expect
This is a common case on the test.
Key is remembering to address
lung maturity.
Decision Making
Help lung maturity through surfactant therapy with agents like Exosurf or Survanta
2 to 5 ml/kg split among 2 to 4 doses
Administer directly down the airway
Change infants position after every dose for 30 seconds to distribute
the agent
Also, if prolonged ventilation is

required, Bronchopulmonary Dysplasia may develop. Be patient
and treat moment to moment.
Provide oxygen via a hood. May use CPAP to oxygenate

Mechanically ventilate with ventilatory failure, use SIMV mode on all infants. May consider
reverse I:E ratio
Note: If X-ray changes from signs of IRDS to hyperinflation and fibrosis, then the problem
may 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
Congenital Heart Defects (Infant)
Visual Assessment
History of pre-term birth
General signs of respiratory distress (grunting, nasal flaring, retractions)
Cyanosis that persists in spite of high FIO2
Defined: Infant is born

with an anatomical malady of the heart or the
vessels that emanate
from the heart.

Heart sounds are abnormal upon auscultation (murmur present)
Special Assessments
Echocardiogram 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
What to expect
Transposition of the Great Vessels
Aorta 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 umbilical
artery. Positive for PDA if difference is greater than 15 torr. (PDA with a right
to left shunt)
Other Problems
Tetralogy of Fallot
Atrial 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
Your skills in recognizing common congenital heart problems

will be tested.
Otherwise, you will be simply
providing supportive care until
surgery.
Neonatal Diaphragmatic Hernia

the diaphragm never
grows closed. Usually
occurs on the left side
Visual Assessment
General respiratory distress, ie grunting, nasal flaring, retractions
Cyanosis
Barrel chest or scaphoid abdomen
Breath sounds absent (usually on left)
Chest-Xrayshow intestinal parts in the chest area. Also may see a mediastinal
shift away from the affected side.
ABGsPoor
Special Assessments
What to expect
This case is more about what you
should not do. Otherwise use
general supportive care.
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
Laryngotracheobronchitis
Visual Assessment
History of cold in the past few days
Barking cough
Age is 6 months to 3 years
Stridor
Tachypnea
Defined: Otherwise
known as Croup. Results
from a viral infection that
illicits inflammation in the
upper airway.

Special Assessments
Lateral 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, severe
or marked stridor, extreme accessory muscle use
Extubation should be done when swelling has ceased.
What to expect
You will likely be tempted to treat
this like Acute Epiglottitis in an
emergency fashion.
Repeated racemic epinephrine
treatments may make you feel
uncomfortable
Acute Epiglottitis

the epiglottis and adjacent upper airway tissues
are infected with a bacteria causing inflammation
and commonly threatening airway patency.
Visual Assessment
Sudden onset of sickness, within 12 hours, often occurs in the evening
Age 3 to 10 years
General appearance may show drooling, hoarseness, quiet cough
May hear a softened inspiratory stridor
Tachypnea and tachycardia
Patient unable to swallow, will usually not be crying, eyes are big
Significantly elevated body temperature, taken axillary, or tympanically
Special Assessments
Lateral neck x-ray will show supraglottic inflammation
What to expect
Decision Making
This case will test your immediately ability to realize that it is an

emergency. Stridor may tempt
you to treat it more casually like
croup.
Primary and immediate concern is establishing and airway as complete closure from inflammation. Since inadvertent stimulation from oral intubation attempts could immediately illicit
an inflammatory response, intubating in a surgical environment is very helpful. There may be
need to place a tracheostomy tube.
There is a good chance you will

see Epiglottitis or Croup on the
test.
Antibiotic therapy to correct bacterial infection

Oxygen therapy at 30 to 40%
Extubate only when inflammation is gone
Bronchiolitis /RSV
Visual Assessment
General signs of respiratory distress including retractions and accessory muscle
use.
Tachypnea and tachycardia
History of recent sickness from ages 2 months to 3 years old
Defined: Acute vital infection of lower respiratory tract usually occurring in infants less than
18 months old. Commonly caused by the respiratory syncytial virus.

Low grade fever
Wheezing, rales, and rhonchi
Chest X-ray show scattered infiltrates and hyperlucency
Decision Making
Primary treatment is delivery of the drug Ribavirin which must be administered via a
SPAG unit (small volume particle aerosol).
Utilize a scavenger system, filters, and masks.
What to expect
There is nothing particularly difficult about this case. You must be
prepared to recommend the use of
a SPAG unit.
Not commonly seen on the exam.
Cystic Fibrosis
Defined: An inherited
disorder resulting in the
mass production of thick
mucus in the lungs.
Visual Assessment
Family history of disease, siblings may have it.
Emaciated in appearance and body frame may be small or age
Sputum production of thick voluminous purulent secretions
Can look like a young COPD patient, barrel-chested
Decreased flow rates such as FEV1
Chest X-raylooks like COPD, hyperinflation, increased A-P diameter, diaphragm
flattening
Special Assessments
Sweat Chloride Testshow sweat chloride > 60 mEq/L
What to expect
Not commonly seen on the exam.
Tests your ability to recognize
secretion removal therapies and
may check your understanding
when and how to modify therapy.
Ex, when CPT doesnt work, use
PEP therapy or ultrasonic nebulization.
Decision Making
Primary treatment relates to the need to mobilize and remove secretions.
Secretion removal promotion therapies:
PEP therapy devices
Chest physiotherapy with postural drainage
Hydration devices such as heated aerosol or ultrasonic nebulization
Vibration therapy
Oxygen as needed
Antibiotic therapy when infection is presentoften is
Medications used commonly include Tobramycin and Pulmozyme
Hypothermia
Visual Assessment
History of exposure to cold. May be seen in homeless persons.
Lethargy and unconsciousness
Bradycardia, bradypnea
Defined: Exposure to
cold such that body temperature falls significantly.

Body 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 temperature and analyzed temperature. Watch out of oxygen (PaO2). In cold, uncorrected
blood, PaO2 may appear higher than it actually is.
What to expect
Not very common. However
when seen, may be seen in conjunction with other problems such
as AIDS, or tuberculosis.
Burn Trauma/CO Poisoning
Defined: Results from

direct exposure to fire
and or smoke. Directly
threatens airway and
oxygen carrying capacity
of the blood.
Visual Assessment
Diagnosis is based largely on historyexposure to fire or smoke. Often occurs in
occupational related cases (fire fighter)
Visible burns about the body and face
Singed nasal and or eyebrow hairs
Cherry-red color of face with CO poisoning
Patient is often confused or unresponsive
Stridor, hoarseness
Breath soundswheezing, rhonchi, rales
ABGsinitially decreased PaCO2, normal PaO2, decreased saturation. Latter may
develop into respiratory acidosis
Chest X-raymay be clear at first, but later may show pulmonary edema and
markedly decreased lung compliance
Special Assessments
COHb 20% or more
What to expect
Fairly common case on the test.
Remember to focus on the airway
and on oxygen carrying capacity
of the blood. Remember to employ isolation techniques. Otherwise, provide general respiratory
therapy.
Decision Making
Protect airway by establishing an artificial airway immediately. Particularly if there is respiratory distress and there are burns about the face.
For CO poisoningstart 100% oxygen immediately even if only suspect itdo not wait
for COHb results
Continue oxygen therapy until COHb level is below 10%.may use hyperbaric medicine if
offeredoften will not be offered.
Practice Reverse isolation (protect the patient from staff)
Mechanically ventilate as needed.
Diabetes
Visual Assessment
History of diabetes
Lethargy, confusion, unresponsiveness
Respiratory rate and patternsignificant in depth and rate with an irregular
rhythm (Kussmauls)
Defined: Condition related to failure of the renal system resulting in

the inability to dispose of
CO2. Respiratory result
is often respiratory ketoacidosis

Pedal Edema
ABGsProfound metabolic acidosis
Urine output is markedly decreased (less than 20 ml per hour)
Special Assessments
Blood 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 expect
May be tempted by profoundly
acidodic pH. Only determine
respiratory failure through the
CO2, or a sudden decrease in
ventilatory volumes and breathing
rate.
AIDS
Defined: Disease of the

immune system commonly resulting in pneumocystis carinii, a type of
pneumonia
Visual Assessment
Previous history of HIV positive test results
Emaciation, unexplained weight-loss, diarrhea, low-grade fevers, night sweats,
Commonly homosexual activity or drug usage is admitted
Special Assessments
Positive HTLV III
ELISA test positive for HIV
Bronchoscopyfrom lung washings or biopsy may show pneumocystis carinii
What to expect
Increasing in frequency on the
exam. Sometimes is combined
with tuberculosis, hypothermia,
and others. Suspect them all.
Decision Making
Exercise Universal Precautions
Aerosolized Pentamadineusually done monthly
When administering Pentamadine, use one-way valves and filters.
LindseyJones
Publ is hers o f S c ien c e an d Me d icine
PO Box 80515
Las Vegas, NV 89129
Copyright 2003 LindseyJones Publishing. All Rights reserved. The enclosed material is intended to facilitate preparation for
the associated credentialing exam. The information is not intended to direct healthcare practitioners on methods of practice.

Pathology Review PDF

Загружено:

Сведения о документе

Исходное описание:

Оригинальное название

Авторское право

Доступные форматы

Поделиться этим документом

Поделиться или встроить документ

Параметры публикации

Этот документ был вам полезен?

Это неприемлемый материал?

Авторское право:

Доступные форматы

Pathology Review PDF

Загружено:

Авторское право:

Доступные форматы

LindseyJones

Defined: Abnormal condition of the alveoli resulting destruction and loss

Defined: Condition where

Bedside (Patient Contact) Assessment

Defined: Abnormal condition where the bronchi

Sleep Apnea Syndrome

Defined: the cessation of

Bedside (Patient Contact) Assessment

Defined: Abnormal constriction of the bronchials

Defined: Asthma that will

Bedside (Patient Contact) Assessment

There is a frequent need to repeat

Defined: Potential loss of

Bedside (Patient Contact) Assessment

Defined: Other neuromuscular diseases or

Defined: Potential loss of

Bedside (Patient Contact) Assessment

Unique to this simulation is the

Defined: May any trauma

This case is usually easy to recognize. You may be tempted by

Very commonly, this case will

Watch for ventilatory fatigue and eventual ventilatory failure

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

Defined: Loss of adherence of the lung to the

Bedside (Patient Contact) Assessment

Defined: Can have variety of complications from

Defined: Any trauma

Bedside (Patient Contact) Assessment

Adult Respiratory Distress Syndrome

Defined: A condition that

Bedside (Patient Contact) Assessment

Also, most often, cardiac output

Defined: Surgery done to

Bedside (Patient Contact) Assessment

Like most neuromuscular cases,

Otherwise, you will be manipulating the ventilator and possibly

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

Defined: Condition where

Defined: Any kind of surgery on the heart

Pulmonary Edema / CHF

Defined: Significant reduction in cardiac output.

This case may feel complicated

You may need to make the distinction between pulmonary

Be prepared to treat ventilatory failure with mechanical ventilation

Defined: Ischemia to the

Bedside (Patient Contact) Assessment

Defined: Situation where

Defined: Involves delivery of an infant is complicated by various problems

If APGAR Score is:

Administer oxygen, place infant in warm, neutrally thermal

Defined: Infant born having meconium in ventilation spaces

Sudden Infant Distress Syndrome

Defined: Sudden apnea

Bedside (Patient Contact) Assessment

Infant Respiratory Distress Syndrome

Defined: Condition in infants where alveolus maturity is below normal.

Also, if prolonged ventilation is

Provide oxygen via a hood. May use CPAP to oxygenate

maintaining pH of 7.25 to 7.40, PaCO2 45 to 60 torr, PaO2 55 to 70 torr.

Congenital Heart Defects (Infant)

Defined: Infant is born

Bedside (Patient Contact) Assessment