LindseyJones

Situation Review

General Assessment

Many times, during the clinical simulations, you will be asked to perform an assessment. The
NBRCs label for this is Information Gathering.
The list of options, from which you may choose, should NOT be looked at in multiple choice
manner. Not only are you to select those answers that are correct, but you should do so in the
right 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 the
patients record should be done first. Visual assessment items include:
General appearance
Color
Medical history
Heart 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 be
done quickly and usually without cost or too much effort from the patient. Bedside
assessment items include:
Breath sounds
Palpation of the chest or trachea
Examination of the upper airway
Blood 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 analysis
Chest X-ray
CBC
Urinalysis
Pulmonary function screening (FEV1, pre and post bronchodilator studies)
Serum electrolytes
ECG
Bilirubin level

General Assessment

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 test
because 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 head
Complete pulmonary function testing (DLCO, Nitrogen washout)
Tensilon test
Bronchogram
Sweat chloride test
Mantoux test
Pulmonary angiogram
Lung perfusion scan
Neck X-ray
Amniocentesis
Acid-fast sputum stain

Special considerations

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

Pulse and medical records are stage I
Recognize the difference between a test and the record of a
test
Example
AmniocentesisSpecial test, costly
Vs.
Amniocentesis resultsalready done, just look at the results

(contd)

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 0
Respiratory 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 an

emergency 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 assessment, 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 the
scene at that point.
Stage I and II are usually combined

Ventilator: Initial Adult Settings

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

Rate

Always between 8 and 12

Immediately 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 volume
Immediately discount every option that shows a tidal volume not in that range

Oxygen

If it is an emergency, then FIO2 is 1.0

Otherwise, 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 to
60%. Remember that oxygen is drug. So, if 40% and 55% is offered, then choose the
lower.

PEEP

Mode

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

Notice that mode is last priority because ALL MODES ARE GOOD. However, on the
NBRC 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 to
determine 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 106 lbs. Then add 7 lbs per inch over feet
WOMAN5 ft starts at 106 lbs. Then add 6 lbs per inch over 5 feet

Adult Ventilator Weaning

An implied objective, when we place someone on a ventilator, is to get them off. Thus, when
performing 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 the
NBRC. There are a lot of studies that show different and seemingly opposing methods to be
equally effective. Most methods involve decremental changes in rate, pressure, oxygen, pressure
support, etc.
Another tricky situation: you have a slightly high or even low PaCO2 and a very poor oxygenation. Since a slightly high PaCO2 (46 torr) or low PaCO2 is not really a problem with ventilation, address the profound hypoxemia first.
Acceptable methods:
Cold cessationremove from the ventilator and monitor
IMV/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 distinguish 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/gh
MIP > - 20 cm H2O
Rate 8 to 20 breaths per minute
RSBI < 100 (RR / Vt(L))
Vd/Vt ratio < 60%

If any of these are not acceptable, the patient is NOT READY TO WEAN!

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
BP
PaCO2
RR

> 20 bpm from baseline (prior to weaning)

> 20 torr from baseline
>10 torr from baseline
>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).

Adult Ventilator Weaning (contd)

Successful Weaning
While there are no explicit expectations on what methods should be used for weaning, there are
some limitations on how far you need to go.
If SIMV rate 4 is accomplished, there is no need to decrease to 2
No need to decrease FIO2 below 0.40
No 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.

Ventilator Troubleshooting

The effective use of mechanical ventilation involves may variablesthe machine itself, the circuit, the patient, etc.
When you are placed in a situation involving a mechanical ventilator and a problem arises (as
manifested by ventilator alarm), you have the task to determine if it is the patient or the machine. Therefore, you must understand those alarms and must know what to think about when
problems 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 signs
ET 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 leakage
Patient inadvertently partially extubated (not always obvious)
Cuff is under-inflated or deflated
Machine
Circuit is disconnected from the patient
Circuit 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 ventilator alarm. In some cases, you will not be given the option to
manually ventilate. In those cases, begin your troubleshooting
START AT THE PATIENT first and work your way to the machine.

Ventilator: Modifying Adult Settings

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

PaCO2

Make changes in rate when PaCO2 is out of range. Increase if PaCO2 is high, decrease
if 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 and
the tidal volume is in the lower part of the range. The best answer, if offered, would be
to 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 the
circuit and pick it before anything else.

PaO2

If PaO2 is low, then increase FIO2 by 10% or so. However, if FIO2 is already .55
or .60, then you want to increase PEEP.
Do not be afraid of high PEEP, even if the patient is on 60% oxygen and the
current PEEP level is 20 cm H20. If hypoxic, then increase PEEP to 22 or 25. The
only problem with increasing PEEP is a threat to hemodynamic values as manifested
by low CVP or CO. When you are not given such information, assume they are normal
keep increasing PEEP.
When over-oxygenation is occurring, FIRST LOWER FIO2 until at 0.6. Then, lower
PEEP.
Do not be too casual about letting patients PaO2 get too high. On the exam, it is a
serious matter because oxygen is a drug. If PaO2 is 118 torr, for example, you will
certainly want to lower it.

Consider:
Sometimes you may be challenged by a high PaCO2 level and a low PaO2 at the same time. Remember 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 oxygenation. Since a slightly high PaCO2 (46 torr) or low PaCO2 is not really a problem with ventilation, address the profound hypoxemia first.

Infant Ventilator Setup

Ventilator Type

Infant Ventilators are usually time cycled pressure limited.

Mode

Always pick SIMV/IMV mode first

Rate

Greater than 20 breaths per minute

Pressure

Greater than 20 cm H2O

FIO2

Same 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%.

PEEP

0 to 2 cm H2O. Although you may advance to higher PEEP settings, (never go more than 8
cm H2O) start at 0 to 2 cm H2O when initially beginning mechanical ventilation. Change
PEEP 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.

Conservative Approach

Always choose the lower pressure when given two pressures that would work. The same is true
with FIO2.
Another point to consider is that FIO2 changes should be very small. It is not uncommon to
reduce FIO2 from 0.7 to 0.68. The smaller the change the better for the infant. Drastic
changes in FIO2 can be very harmful to infants.

Adult Oxygen Therapy

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

COPD level

2428%

Usually 1-2 lpm nasal cannula or a venturi mask

Adult Therapeutic level

3060%

(40-55%) is better. Usually 60% is not an option. Will more

likely be 55%

Emergency level
100%

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

Titration of oxygen

In cases where 60% is not enough to maintain good color or adequate PaO2, then employ CPAP or BIPAP.

Modifying Therapy

This is a very encompassing area that is impossible to cover every potential situation. The
NBRC will constantly be testing your ability to recognize the need to modify therapy. Perhaps
the 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 down
Possible actions: Stop the therapy, switch to other secretion mobilizing therapy like PEP
therapy or incentive spirometry.
Problem: Patients secretions remain thick in spite of significant hydration therapy with
heated aerosol
Possible actions: Give Mucomyst, try ultrasonic nebulization
Problem: Patient experiences PVC when suctioning for more than 10 seconds
Possible 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 machine.
Possible actions: increase sensitivity
Problem: patient experiences tachycardia after inhaled Albuterol treatments
Possible 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

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 to
establish an artificial airway, know when the artificial airway is threatened, and recognize signs
and symptoms of airway problems.

Establishing an artificial airway

Establish an airway when:
The natural airway is threatened by current or potential inflammation as seen in
burn trauma, upper airway surgery, and bacterial infection (acute epiglottitis).
The airway may be traumatized. Seen in diving accident victims or other
accidents 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 sputum
production through the lungs. Fulminating pulmonary edema is a good
example.
The patient shows marked signs of ventilatory problems, such as sternal
retractions, nasal flaring, supraventricular retractions, etc.

Procedural considerations
Use the head-tilt/chin lift in oral intubation
Have tubes of various sizes on hand
Have 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 but
bronchoscopy should be your first step.
The ET tube should be advanced 2 cm beyond the carina, OR 1 inch beyond
the 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 be
used.

Intubation with a bronchoscope is preferred above all other methods

when complicated intubation is suspected.

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 to
REMOVE THE TUBE. Do not be afraid of this response. It is very often
appropriate, 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, are
heavily diminished or absent in one side. Distinguish this situation from a
pneumothorax by the patients conditionvery much worse if pneumothorax.

Cardiac Arrhythmias

There are several situations on the clinical simulations that involve cardiac arrhythmias and their
treatment. Cardiac arrhythmias may be associated with a specific disease process, but are often
the 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 administration
Secondary treatment involves LIDOCAINE
If PVCs occur during specific therapy or medication administration, then you need to
STOP 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 acidosis through bicarbonate administration. If a transition from V-Fib to V-tach occurs while you
are with the patient, then you may do a PRECORDIAL THUMP.

Persistent v-tach or v-fib

Follow a specific course of defibrillation and medication administration

Chest compressionsintubationestablish IV access
Then:
Epinephrine
Defibrillate at 360 watt/sec
Lidocaine
Defibrillate at 360 watt/sec
Lidocaine
Defibrillate at 360 watt/sec
Bretylium
Defibrillate at 360 watt/sec
More Bretylium
Defibrillate 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 cessation of contractions.
Primary treatment is CARDIAC COMPRESSIONS and PACING
Secondary treatment is EPINEPHRINE, ATROPINE

NO DEFIBRILLATION with asystole !

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)

Bronchoconstriction

Unlike a real hospital setting, a breathing treatment does not cure everything. The type of medication 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 aerosol. Usually, it is done with a small volume nebulizer. The test may refer to it simply as
Aerosolilzed Albuterol, etc.

Intravenous/Pill

Backdoor bronchodilators include all Xanthine medications including, Aminophylline, Theophylline and others.

Subcutaneous

1:1000 strength epinephrine may be give in extreme cases where repeated traditional bronchodilators are not working. Usually happens in cases such as Status Asthmaticus. It is acceptable to
deliver three successive doses, 20 minutes apart.

Common Bronchodilators
Albuterol
0.5 mL
Terbutaline
0.5 mL
Bitolterol
1.25 mL
Pirbuterol
2 puffs
Salmeterol
2 puffs
Metaprotereno 0.3 mL

Q4 hours
Q4 hours
QID
Q 4 6 hours
BID
Q4 hours

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

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 problems in the clinical simulations relate to situations rather than disease
MANY situations and diseases, HOWEVER, are emergencies by definition. As such, the must
be dealt with in a different manner.

Emergency Situations

Any situation that threatens the four VITAL FUNCTIONS OF LIFE is an emergency. The
function that is at risk should be addressed first.
Cardiac arrestcompressions and medications
Acutely inflamed airwayestablish an artificial airway
Marked cyanosis100% oxygen
Loss of blood pressuregive fluids, administer cardiac drugs
If several function are in jeopardy, then they should be addressed in order (ventilation, oxygenation, 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 with
the 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.
Pneumothorax
Pulmonary Emboli
Pulmonary Edema
Congestive heart failure
CO poisoning
Any Trauma involving head, chest, neck, lungs, burn
Status Asthmaticus

Surfactant Therapy

The primary treatment for IRDS or lung immaturity in newborn infants (especially premature
infants) is the administration of surfactant.

Surfactant Therapy with Survanta (beracant)

Dose:

100 mL/kg
Divide into 4 doses
Turn baby to initial position
Instill surfactant down ET tube
Vigorously ventilate for 30 seconds
Repeat with other doses, changing the position of the
infant with each dose

Surfactant Therapy with Exosurf

Dose:
2.5 mL/kg
Divide doses
Place infant on one side
Instill
Ventilate
Change side and administer next dose

Associations

You will not find many pictures on the simulations. Thusly, everything is conveyed by words or
phrases. Many of those words or phrases can be uniquely associated with a certain diseases or
conditions.
For instance, if an X-ray is described as having a Batwing pattern, then the likely problem is
pulmonary edema.
Provided in the next couple of pages is a list of descriptors that are commonly associated with
specific diseases or conditions. As you review the list, keep in mind that they are not all definite
in their associations. For example, when you see that somewhat is experiencing tachycardia, you
should 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 you
think 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 should
set out to gather data that proves or disproves your theory as you advance through each simulation case.

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

Butterfly pattern on X-ray

Resp Distress Syndrome

(ARDS) or (IRDS)

Keep FIO2 low as possible, keep ventilatory pressures

down

Reticulogranular pattern on X-ray

Resp Distress Syndrome

(ARDS) or (IRDS)

Keep FIO2 low as possible, keep ventilatory pressures

down

Pitting edmea

CHF

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, inappropriate

responses

Drug overdose

Anxiety, nervous

Hypoxemia

Angry, irritable, or combative

Electrolyte imbalance

Panic

Severe asthma attack

Orthopnea

CHF

General malaise

Electrolyte imbalance

Digital clubbing

COPD

Diaphoresis

Heart failure, fever, tuberculosis if night time

Night sweats

Tuberculosis

Ashen or pallor color

Anemia, acute blood loss

Increased A-P diameter

COPD

Kussmauls breathing

Metabolic acidosis, diabetic, renal failure

Apneustic breathing

Brain trauma or tumor

Muscular hypertrophy

COPD

Retractions

Significant resp distress

in infants

100% oxygen, chest x-ray, chest tubes if positive

Cardiac drugs, digitalis, digoxin

Maintain good fluid balance (often diurese patient)

Protect airway (may intubate)

Deliver Narcan if narcotic overdose)
Ventilation is at risk (unpredictable CNS depression)
Address the underlying problem, resolve the hypoxemia
Fix it (delivery fluids, administer specific electrolytes)
Give oxygen, bronchodilators
Cardiac drugs, proper fluid maintenance (often diuretics)
Fix it
Low oxygen delivery
Address underlying problem
Treat the disease generally
Stop bleeding, give blood
Treat disease generally
Treat underlying problem
Treat the problem
Treat the disease
Support ventilation, administer oxygen

Associations, Contd
Descriptor

Association

Paradoxical chest movement

Flail chest

Pulses paradoxus

Status asthmaticus, severe

air-trapping

Flat to percussion

Atelectasis

Dull to percussion

Fluid-filled, pneumonia,
pleural effusion

Hyperresonant to percussion

Pneumothorax

Course rales

Rhonchi

Medium rales

Action
Ensure ventilation, watch for pneumothorax
Address the underlying problem
Hyperinflation therapy
Address underlying problem
Chest tubes, chest X-ray
Suction patient if cannot cough, otherwise anything to mobilize secretions
Needs anything to mobilize secretions, CPT, IPPB, PEP
therapy, etc

Fine rales

CHF, pulmonary edema

Wheezing

Bronchoconstriction

Stridor

Diurese the patient, provide positive pressure ventilation,

IPPB, cardiac drugs such as digitalis
Administer bronchodilator
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), double

vision (Diplopia), dysphagia

Treat underlying disease

Myasthenia Gravis

Copyright 2004 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.