Acute Care- Resp Flashcards
Textbook triad of PE
Pleuritic chest pain
Dyspnoea
Haemoptysis
4 signs of PE
Tachypnoea
Clear chest/ crackles
Tachycardia
Fever
PE initial Ix
ECG
CXR
If low pre-test probability: PERC
2-level Wells score
List 9 non-modifiable risk factors for PE
DVT
Recent surgery
Immobility
Previous DVT/ PE
Malignancy
Anti phospholipid syndrome
Recent MI
Age
Pregnancy + 6w postpartum
List 4 modifiable risk factors for PE
Long duration travel
Obesity
COCP
Smoking
Describe action based on Well’s score in PE
Low Probability ,<4: use D-dimer
High Probability > 4: required imaging (CTPA)
ECG in PE
May be normal
Sinus tachycardia (most common), RAD or RBBB
S1Q3T3 pattern (less common)
S1Q3T3 pattern?
S wave in lead 1
Q wave in lead 3
T-wave inversion in lead 3
What mneumonic can be used to remember the PERC criteria?
H- hormone use (oestrogen)
A- Age >50
D- DVT or PE hx
C- Coughing blood
L- Leg swelling disparity
O- O2 <95%
T- Tachycardia >100bpm
S- Surgery or Trauma (recent)
7 features of the 2-level Wells score
C- Clinical features of DVT (3)
A- Alternative dx less likely (3)
T- Tachycardia (1.5)
P- Previous DVT or PE (1.5)
I- Immobilisation >3 days (1.5)
C- Cancer (1)
H- Haemoptysis (1)
What is the initial management of a patient with a Wells score >4?
Admit + immediate CTPA
(if NA immediately, anticoagulant in interim)
If CTPA is negative in a patient with a Wells score >4, what should be performed?
Proximal leg vein USS
In a patient with renal impairment and a Wells score >4, what investigation is preferred?
V/Q scan
(doesn’t require contrast)
How should patients be further assessed with a Wells score of 4 or less?
D-dimer with results available within 4h (if >4 anticoagulate)
D-dimer +ve: CTPA
D-dimer -ve: consider alternative dx (+ stop interim anticoagulant)
What should be offered as interim anticoagulation if appropriate?
Apixaban
or
Rivaroxaban
(if unsuitable- 5 days LMWH, then Dabigatran
What tool determines whether a patient with PE can be managed as an outpatient?
Pulmonary Embolism Severity Index (PESI)
How should haemodynamically stable patients with confirmed PE be managed?
DOAC: Apixapan (10mg BD) or Rivaroxaban (15mg BD)
+ PESI risk assessment
If DOACs are unsuitable, what other form of anticoagulation can be used in a confirmed PE?
LMWH
Followed by Dabigatran or Edoxaban
OR
LMWH
Followed by Vitamin K antagonist i.e. Warfarin
What is the recommended management of cancer patients with PE?
DOACs (unless CI)
For what duration should patients with PE be on anticoagulation?
Provoked: 3 months
Unprovoked: 6 months
How are haemodynamically unstable PE patients managed?
UFH
Thrombolysis: Alteplase IV
Switch to DOAC after several hours on UFH post-thrombolysis
What surgical options are available in massive PE management?
Embolectomy
What primary prevention measures can be taken for PE?
Compression stockings
DOAC/ LMWH
Good mobilisation + adequate hydration
PE counselling
We think you have a pulmonary embolism. A blood clot has developed in one of the deep veins in your legs, travelled up your legs + body to block one of the blood vessels to your lungs.
We need to keep you in hospital to do a scan of your lungs to confirm and locate the blood clot. Before the scan results are back, we need to give you a blood thinning medication through an injection to prevent further clots from blocking your lungs. We do not have to remove the blood clot that is currently blocking the vessel as it will dissolve on its own within the next few days. We will also give you some oxygen to support your breathing and some painkillers for your chest and calf pain.
Most important RF for PTX
SMOKING
5 non-modifiable RF for PTX
FH
Male
Young
Slim + tall stature
Homocystinuria
2 Sx PTX
Acute onset pleuritic chest pain
SOB
4 signs of PTX
Reduced chest wall movement
Absent breath sounds
Hyper-resonant percussion
Reduced vocal fremitus
Ix for PTX
PA CXR
Visible rim between lung margin + chest wall
Absence of lung markings between lung margin + chest wall
In patients unable to sit upright, what imaging may be considered in suspected PTX?
USS
CT
Describe the immediate management for a tension pneumothorax
Cardiac arrest call
Immediate decompression:
Insert large bore cannula into 2nd ICS MCL- hiss of air
High flow O2
Insert chest drain once decompressed + regular analgesia
How does management of tension pneumothorax secondary to trauma differ?
Decompression with open thoracostomy
What is considered ‘minimally symptomatic’ in primary spontaneous pneumothorax? How should this be managed?
No significant pain
No breathlessness
No physiological compromise
If minimally symptomatic conservative Mx regardless of size
What is conservative management for a minimally symptomatic primary pneumothorax?
Observation 4-6h
Supplemental O2
Regular review as OP every 2-4 days
Mx of small (<2cm) symptomatic primary PTX
Needle aspiration
Mx of large (>2cm) symptomatic primary PTX
Needle aspiration
Observe 4-6h
If unsuccessful; chest drain + admit
How should aspiration be performed?
Aspirate up to 2.5L
Use 16-18G cannula
How should a small secondary pneumothorax be managed?
Admit + observe 24h
High flow O2
How should a moderate secondary pneumothorax be managed?
Needle aspiration
High flow O2
Admit + observe 24h
How should a large/ symptomatic secondary pneumothorax be managed?
Admit
Chest drain
High flow O2
What does the immediate management of pneumothorax involve?
Supplemental Oxygen to relieve hypoxia + accelerate resorption of the pneumothorax
What is a complication of rapid decompression pneumothorax?
Re-expansion pulmonary oedema
How does re-expansion pulmonary oedema present?
Asymptomatic radiographic changes to complete cardiopulmonary collapse
Acute onset dyspnoea
Cough
Hypoxaemia
Signs unilateral to PTX (unlike HF)
Give 2 pieces of advice to a patient who has had a pneumothorax
Avoid air travel until 1w post CXR check / 2w after successful drainage if no residual air
Avoid diving indefinitely
What surgical management can be used for recurrence prevention of Pneumothoraces?
Refer for Video assisted thoracoscopic surgery (VATS) to perform:
Mechanical/ chemical pleurodesis +/- bullectomy
Counselling for PTX
Air has accumulated in the space around your lung where it’s not meant to be, causing your lung to collapse. This is quite a common occurrence, and often there is no clear cause.
To help you feel better, we need to remove the air from that space to allow your lung to re-expand.
To do this, we will need to insert a needle on the side of your chest just below your underarm to allow the trapped air to leak out. If this doesn’t work, we may have to insert a drain in the same location.
For this reason, we will have to keep you in the hospital to keep an eye on you and do another scan of your chest in 1-2 days to ensure all the air has fully escaped before we are happy to let you go home.
Moderate exacerbation of asthma
PEFR 50-75% best/ predicted
Speech normal
RR <25/ min
HR <110 bpm
4 signs of severe acute asthma exacerbation
PEFR 33-50% best/ predicted
Can’t complete sentences
RR >25/min
HR >110 bpm
6 signs of life-threatening acute asthma exacerbation
PEFR <33% best/ predicted
O2 sats <92%
Normal pCO2 indicates exhaustion
Silent chest, cyanosis, or feeble respiratory effort
Bradycardia, dysrhythmia or hypotension
Exhaustion, confusion or coma
What characterises near-fatal asthma exacerbation?
Raised pCO2 +/or requiring mechanical ventilation with raised inflation pressures
Ix in acute asthma
ABG: if O2 <92%
CXR: if life threatening/ suspected PTX
Describe management of patients with mild-moderate acute exacerbation of asthma
Salbutamol via pressurised MDI, 2-10 puffs every 10-20 mins
40-50mg Prednisolone PO daily for at least 5 days
+/- O2
Describe management of patients with severe acute exacerbation of asthma
Salbutamol 5mg via oxygen driven nebuliser over 20-30 mins
+
Ipratropium nebs 500 micrograms every 4-6h
+
Prednisolone 40-50mg PO
What can be given if severe acute asthma exacerbation is not responsive to initial treatment?
Discuss with senior
IV Magnesium Sulfate
Describe management of patients with life-threatening acute exacerbation of asthma
Salbutamol 5mg via oxygen driven nebuliser over 20-30 mins
+
Ipratropium nebs 500 micrograms every 4-6h
+
Prednisolone 40-50mg PO or Hydrocortisone IV
What can be given if life-threatening asthma exacerbation is not responsive to initial treatment?
Discuss with senior
IV Magnesium Sulfate
IV Aminophylline
Intubation + mechanical ventilation
What is the criteria for discharge following admission for acute exacerbation of asthma?
Stable on discharge meds (no O2 or news) for 12-24h
Inhaler technique checked + recorded
PEF >75% of best or predicted
Counselling for asthma attack
When muscles of the air passages in the lungs go into spasm.
The airways become narrowed, which makes breathing more difficult.
Sometimes there is a recognised trigger for an attack, e.g. a cold, a drug, cigarette smoke or an allergy. At other times, there is no obvious trigger.
Anaphylaxis Mx
- Call for help
- Remove trigger + lie flat
- Adrenaline IM 500 micrograms (repeat up to every 5 mins)
- Establish airway, high flow O2, apply monitoring, fluid bolus
What volume of adrenaline is given in anaphylaxis? At what site?
0.5ml 1 in 1000
to anterolateral aspect of middle third of the thigh.
Describe Mx of anaphylaxis post-stablilisation
Non-sedating antihistamine PO esp. in patients with persisting skin Sx (urticaria +/or angioedema)
Refer all with a new dx of anaphylaxis to a specialist allergy clinic
Give 2 adrenaline injectors as interim measure before specialist allergy assessment (unless reaction was drug-induced) + train how to use
Risk-stratified approach to discharge should be taken as biphasic reactions can occur in up to 20%
What can be measured to determine whether a patient has had a true episode of anaphylaxis?
Serum Tryptase (remains elevated up to 12h after)
What criteria must be met to allow for fast track discharge following anaphylaxis?
Good response to single dose of adrenaline
Complete resolution of Sx
Has been given an adrenaline auto-injector + trained how to use it
Adequate supervision following discharge
When is a patient kept in for a minimum of 6h following anaphylaxis?
If 2 doses of IM adrenaline needed
Previous biphasic reaction
Under what circumstances must a patient be kept in for a minimum of 12h following anaphylaxis ?
Severe reaction requiring > 2 doses IM adrenaline
Patient has severe asthma
Possibility of an ongoing reaction (e.g. slow-release medication)
Patient presents late at night
Patient in areas where access to emergency access care may be difficult
Observation for at 12h following Sx resolution
