Acute respiratory failure (most of this in Vandy handbook)

Modes of oxygen

• NC - up to ~6L, ~40% FiO2
• HFNC - up to ~15L, 80% FiO2
• Venti mask - not used often, controlled with attachable and switchable filters
• Non-rebreather - up to ~100% FiO2, turn flow up all the way, fill up reservoir first then apply
• bipap - usu ICU, careful with aspiration risk, can adjust insp/exp pressures, up to 100% FiO2
• optiflow - up to 60L, 100% FiO2, usu ICU

Get help

• Esp if res-interning, don't hesitate to call/ask nurse to call Rapid Response Team (1-1111)

Differential

(pt with known COPD desatting)

• Most likely: COPD; other most common: CHF; must not miss: PE

Order

• CXR, EKG, trop, BNP
• bipap (not available on regular nursing floors), duonebs, lasix

COPD exacerbation

• fairly algorithmic:
  • bipap
  • O2 for sat 90-94%, or >88% if on O2 at home
  • Prednisone 40mg x 5d
  • Albuterol/ipatropium q4-q6
  • abx

LASIX

• feel free to give big push (e.g. 160) of lasix if any concern for volume overload
• even if AKI - oxygenation takes priority, can rehydrate kidneys later

Anaphylaxis

• call RRT (have friends - pt can need intubation, etc.)
• 0.3mg of 1mg/ml IM epinephrine (on crash carts) (if not responding, put on drip)
• O2
• stop offending meds/infusions

PE

• ddx: PE, pneumonia, STEMI, PTX (hence EKG, CTA or CXR if can't get CTA quickly, trop, BNP)
• if AKI: can get VQ scan instead of CTA, but if suspicion is high start treating
• massive (+hypotension): catheter-directed thrombolysis
• submassive (normotensive, RV dysfxn + inc trop or BNP): heparin gtt or lovenox (preferred if possible - therapeutic more quickly with less futzing)

Afib w RVR

• HR >120 and stable: IV metop 5mg (up to 3x @ 5min intervals) or dilt (avoid if reduced EF, and often don't know, so usu metop)
• HR <120 and stable: oral metop tartrate 25mg
• unstable: cardioversion
• also something about amio drip that I missed, usu done in MICU/CCU