Acute Resp Flashcards
A gentleman presents with acute breathlessness and chest pain. O/E his respiratory rate is 25bpm with good air entry in all fields. His ECG shows right axis deviation. What is the most likely diagnosis?
Pneumothorax
Pneumonia
COPD
Pulmonary Embolism
Pulmonary Embolism
A 35 year old lady presents with acute onset SOB, chest pain and one episode of haemoptysis. She has recently noticed a swelling in the left leg. O/E her RR is 28 and HR is 105. You suspect a pulmonary embolism. What is the most appropriate investigation to perform? Chest X-Ray CTPA D-Dimer ECG
CTPA
A 23 year old student presents to A&E with SOB. He says it came on suddenly. O/E his trachea is undisplaced with reduced breath sounds on the left. A chest x-ray confirms a 1cm pneumothorax. What is the most appropriate management?
Immediate chest decompression
Intercostal drain
Aspiration
High flow oxygen
High flow oxygen
What is the presentation of a pulmonary embolism
SUDDEN ONSET 1. SOB 2. pleuritic chest pain (pain on inspiration) 3. +/- haemoptysis 4. +/- haemodynamic compromise
What are signs of pulmonary embolism
- Tachypnoea
- tachycardia
- cyanosis
- May have sign of shock
What scoring system is used to investigate pulmonary embolism
Well’s score
Describe the Well’s criteria for PE
3 POINTS 1. signs and symptoms of PE 2. alternative diagnosis unlikely 1.5 POINTS 1. Immobile for 3 days/surgery in the past 4 weeks 2. HR>100 3. Previous PE/DVT 1 POINT 1. Haemoptysis 2. Malignancy
Pulmonary embolism investigations: how is the Well’s criteria used
Well’s score:
>4 (PE likely): admit to hospital and perform an immediate CTPA
<4 (PE unlikely): perform a D-dimer
-ve: consider different diagnosis
Pulmonary embolism investigations: how is the Well’s criteria used
Well’s score:
>4 (PE likely): admit to hospital and perform an immediate CTPA
<4 (PE unlikely): perform a D-dimer
-ve: consider different diagnosis
+ve: admit to hospital to perform an immediate CTPA
What other investigations should be considered with a possible diagnosis of pulmonary embolism
ECG
- sinus tachycardia
- right axis deviation
- RBBB
- S1 Q3 T3 (very uncommon)
CXR
- pleural effusion
- elevation of hemidiaphragm
What is the management plan for pulmonary embolism
Analgesia
oxygen
fluids
If haemodynamically stable:
- LMWH or fondaparinux for at least 5 days or until INR >2
- start oral anticoagulation WARFARIN at the same time
If haemodynamically unstable:
- Thrombolysis e.g. Alteplase
Define pneumothorax
accumulation of air in the pleural space
What is a primary spontaneous pneumothorax
a pneumothorax with no underlying respiratory illness
What is a secondary spontaneous pneumothorax
a pneumothorax which is associated with underlying lung pathology
such as COPD, CF, Lung Ca
What is the presentation of a pneumothorax
SUDDEN ONSET
- SOB: severity depends on size of pneumothorax
- chest pain: same side as pneumothorax
What are the signs of pneumothorax
- reduced/absent breath sounds
- reduced/absent vocal resonance
- hyper-resonant
- reduced chest expansion
What are the risk factors for pneumothorax
- underlying lung disease
- connective tissue disorders (e.g. Marfans)
- smoking
- trauma
What are the 2 main investigations to diagnose a pneumothorax
- CXR
- look for lung markings to differentiate
What are the 2 main investigations to diagnose a pneumothorax
- CXR
- look for lung markings to differentiate between bullae and pneumothorax
- important to determine size of pneumothorax - CT
- will also differentiate between emphysematous bullae
How does the size of a primary pneumothorax affect its management (where patient is <50 years old)
<2 cm: oxygen + consider discharge
> 2 cm: Aspiration
If unsuccessful: intercostal drain
How does the size of a secondary pneumothorax (or the patient is >50 years old) affects its management plan
<1 cm: High flow oxygen
1-2 cm: Aspiration
If size is reduced to <1 cm: high flow oxygen
If size is >1 cm: put in an intercostal drain
> 2 cm: put in an intercostal drain
What is a tension pneumothorax
Build up of air in the pleural space due to a one way valve
Air can get into the space during inspiration but not out during expiration
This pushes the mediastinum across cavity
What is a tension pneumothorax
Build up of air in the pleural space due to a one way valve
Air can get into the space during inspiration but not out during expiration
This pushes the mediastinum across cavity
This reduces venous return to the heart
On examination, how is a tension pneumothorax picked up
- reduced breath sounds
- tachypneoa
- tachycardia
- Deviated trachea
- Distended neck veins
- Displaced apex beat
