Acute Respiratory

Question 1

Acute SOB DDx

Answer 1

I would normally like to rule out the more sinister causes of acute SOB first, including:
o Pulmonary: PE, PTX, Pneumonia/COPD, FB inhalation, Asthma
o Cardiac: Acute HF, ACS, Arrhythmia
o And other systemic causes such as Anaphylaxis or Sepsis

Once these have been ruled out I would consider less common DDx such as metabolic acidosis, severe anaemia, endocrine issues such as tumors or thyrotoxicosis, obstructing lung Ca, long standing infection such as TB, or panic attack

Question 2

Acute asthma - Airway - classification of severity

Answer 2

• M: PEFR 50-75%
• S: Respiratory distress, wheeze. PEFR<50%.
• LT: No effort. PEFR<33%.
• NF: No effort, cyanosis

Question 3

Acute asthma - Airway - action

Answer 3

• LT/NF: 2222 for ?I+V
• S+: Alert seniors and consider admission to ICU or HDU if poor treatment response

Question 4

Acute asthma - Breathing - assessment + actions

Answer 4

• S: RR>30 HR>120
• LT: SpO2<92, BP<90/60, cyanosis
• ## !! Portable CXR: S+ if ?PTX
• Mod-: 20 puff burst MDI + 0.5mg/kg pred PO
• S+: O2 driven back to back nebs [2.5mg Salb + 0.5mg IpBrom] + IV Hycort 100-200mg

Question 5

Acute asthma - Circulation - assessment + actions

Answer 5

• LT: ABG PaO2<8 (but PaCO2 4-6), high CRT
• NF: ABG PaO2<8 + PaCO2>6 (T1RF)
• ## Bloods: ABG, FBC, U&E, CRP/ESR, BC if ?infective trigger
• Consider MgSulph IV 1-2g
• Consider aminophylline inf if treatment refractory (in resus, resp unit or HDU/ITU)

Question 6

Disability assessment in asthma

Answer 6

• S: single word sentences
• LT: low consciousness

Question 7

Exposure assessment in asthma

Answer 7

Ensure no rash ?DDx of wheeze anaphylaxis

Question 8

SAMPLE in asthma

Answer 8

Ask about
- Current treatment
- Recent changes
- Recent illnesses
- Previous hosp / ITU admissions
- Other PMHx
- Allergies
- Last meal in case tube

Question 9

Summary of asthma ABCDE and management (IMT perspective)

Answer 9

CALL FOR SENIOR/SPR HELP if severe/life threatening attack/paeds
CALL ANESTHETIST if LT/NF (even if LT, patient may deteriorate)

ABCDE approach (will probs get stuck on B but get obs!)
[OSIHAM]
- O2 via NRBM
- 5mg Salb + 0.5mg IpBrom nebs - can give back to back
- IV 100-200mg Hydrocortisone if S/LT/NF (or PO Pred 30mg OD if less severe)
- Consider Aminophylline [cardiac monitoring] and/or MgSulph 1-2g [monitor BP] and/or IV Salbutamol

Monitoring: Cardiac monitor + VBG once every 30mins-1h (hypoK and hyperGly)

Summon anaesthetic help if PCO2 increasing (NF threshold Pco2=6)
o Consider intubation and mechanical ventilation
o Also summon help if considering aminophylline or salbutamol IV

Treat cause: infection etc.

Question 10

Acute COPD exacerbation - airway

Answer 10

Findings
* Respiratory distress
* Pursing of lips, Prolonged expiratory phase (PEP)

Action
* Severe <88% O2 refractory to Tx: consider BiPAP & INVOLVE SENIOR

Question 11

Acute COPD exacerbation - breathing

Answer 11

Assessment
* Inspect: barrel chest, PEP, low cricosternal distance
* Percuss: hyperinflated, ?PTX
* Auscultate: crackles, distant breath sounds, PEP.
* SpO2: <88%, maintain 88-92%
* RR high
* ? portable CXR in A&E - infection, AHF, PTX

Action
* O2 1-2L via nasal cannula or if severe – aim for 88-92%
* Venturi mask on 24% FiO2

Question 12

Acute COPD exacerbation - Circulation

Answer 12

Assessment
* ?sepsis (low BP, high HR, low CRT)
* ? acute HF (cor pulmonale)
* Acute Exac: Bounding pulse, warm peripheries (CO2 retention)
* ECG: (?cor pulmonale)
* Bloods: ABG (T2RF in acute exac), FBC (infection marker) CRP/ESR, U&E

Action
* If Septic: 3i3o (FAO UCL) *
* If Acute exac: 0.5-5-50-100 (Nebulizer 0.5 IpBrom + 5 Salb + 50mg Pred + 100mg Doxy)
* If PTX decompress if haemodynamically unstable/periarrest - Wide bore needle in 5th ICS in MAXL (update from 2ICS MCL, ATLS 10th Edition) or insertion of chest drain if time / stability allows

Question 13

Summary of management in acute COPD exacerbation

Answer 13

Salbutamol 5mg + Iratropium 0.5mg nebulizer, every 20 min

PO Steroid - Prednisolone 50mg OD
 Continue for 5 days then transition to inhaled budesonide

Airway clearance
 Venturi mask 24% Fio2
 +Pressure ventilation (PPV) if severe
* Noninvasive first NIPPV
* Invasive if needed  step to HDU/ITU

PO antibiotic if infective exacerbation
 Doxycycline 100mg PO OD for 10 days

Step up care to HDU if refractory to treatment and ITU if requiring invasive ventilation/sepsis likely

Question 14

Acute HF - presentation

Answer 14

Acute SOB, ?chest pain, ?leg swelling/abdo swelling. Clinically: Cyanosis, tachycardia, SOB, cardiac wheeze, pulsus alternans, gallop rhythm

Question 15

Acute HF summary of management

Answer 15

Acute (usually presents with pulmonary odema, severe SOB): S-FON-D

Initial treatment of PULMONARY ODEMA:
o Sit up
o Frusemide (80 IV)
o Oxygen,
o IV GTN (5mcg/min)

If in cardiogenic shock with high intravascular volume: Involve ITU (-D)
 Consider initiating dobutamine (if in systolic dysfunction, guided by TTE)
 Swan-Ganz catheter to ascertain RV/PA/PCW pressures
 Consider mechanical support - intra-aortic balloon pump, Impella, VA-ECMO

Treat underlying cause

Question 16

Causes of acute HF

Answer 16

Ischaemia (most common cause)
S-MONARCH
* Sit up, Morphine, Oxygen, IV GTN (given already)
* Aspirin, Clopidogrel, Heparin (LMW)
* Angiography +/- proceed, might need to be supported by MCS e.g., impella

Valvulopathy/structural disease
 Offload and consider inpatient urgent procedure
 If pericardial effusion/tamonade, pericardiocentesis

Acute myocarditis
 Send viral panel, CMRI, admit, consult micro

Acute RHF
 Most common due to PE
 Other causes include TPPM, acute on chronic pHTN
 Ensure no hypoxia, careful fluid balance guided by echo, careful choice of vasoactives to reduce PA constriction (e..g, enoxmone) and consider RV support devices

Endocrine: Phaeo, thyroiditis
 Phaeo Hypertensive crisis - Acute HF: IV alpha (phentolamine) or B-Blocker (Metoprolol 5-10mg IV or Labetalol 20mg)
* IV GTN (5mcg IV)
* IV nitroprusside
 Long term treat – surgery (PH) or medical (T)

Question 17

Pneumothorax management

Answer 17

Flail chest:
Immediate surgical review if raised trop, 3+ consecutive ribs 3-10, open fractures, hypoxia

Tension PTX:
o ABCDE assessment
o B: Put on Max O2 (Sats will be low, airway to side),
o CALL FOR SENIOR HELP
o Immediately insert a large bore (14-g) needle into 5ICS MAL (ATLS 2018 update from prev 2ICS MCV).
o After the needle, chest tube or small bore catheter inserted in 4ICS MAX-L later

Small PTX (<2cm lung margin to side chest wall) Asymptomatic
o Monitor and give analgesia, give Oxygen therapy

Medium PTX, >2cm from wall:
o May need aspiration using large bore cannula and syringe (percutaneous needle aspiration), 2.5L/time, from 2ICS MCV
o Supplemental oxygen therapy
o May need drain

Recurrent pneumothoraces:
o Video assisted thoracoscopy with stapling of air leak and pleurodesis (fusion of visceral and parietal pleura)

Advice: avoiding travel and diving until next follow up.

Secondary: treat the cause, admit if high risk of recurrence.

Question 18

PE presentation and key features to ask for

Answer 18

Cardiac arrest, syncope, RH failure. Pleuritic chest pain + Haemoptysis.

RF: pregnant, hypercoagulable, DVT, post op, OCP, obesity, heart failure, malignancy

Question 19

ABCDE features in PE

Answer 19

A
* Patent usually ok

B
* Low SpO2, high RR
* Assess PE score using YEARS or Wells

C
* Tachycardia, low BP
* HS: I+II, Loud/Split P2, S4
* ECG: Tachy, RAD, RBBB, S1Q3T3
* Bloods: D-Dimer, FBC, WCC, clotting, UE, LFT

D/E
* Glucose, AVPU, Pupils
* Injury from syncope

Ask/assess about contraindications to thrombolysis (high BP, recent stroke. major trauma, CNS neoplasm, ICH or GI bleeding)

Question 20

Management in PE - massive/high risk

Answer 20

Resuscitation (Thrombolysis –see below- and 90 minutes of CPR)

Respiratory:
 Call ITU, may need mechanical intubation. Aim for 94/98% O2.

IV fluids
 If SBP<90, administer IV fluids (500mL fluid challenge)

Vasoactive agents
 If SBP<90 -> vasoactive support

Anticoagulation
 tLMWH

IF haemofynamically unstable of RV strain -> Thrombolysis or embolectomy or catheter directed therapy
 Alteplase 100mg IV over 2h
 Aware of CIs

Question 21

Management of intermediate-high risk PE

Answer 21

o Respiratory support, O2 only
o Anticoagulate (tLMWH / DOAC [UFH renal])
o IV fluids
o Thrombolysis or embolectomy or catheter directed therapy if saddle

Question 22

Sepsis mangement

Answer 22

Abx choice: follow local guidelines and as per most likely cause of infection
 CAP: IV Co-Amox 1.2 TDS + Clarythro 500 BD
 HAP: Vanc+Cipro
 ITU: PipTaz 4.5 IV TDS
 Uro: IV Gentamicin 1.2g TDS

Remove catheter, obtain culture and then tailor tx accordingly.

Septic screen
 CXR
 Urine dip and MCS
 Blood cultures
 Other investigations under clinical indication: LP and MCS, Wound swab and MCS, Urethral/HVS and MCS, TOE/TTE for ?IE and appropriate cultures (x3), Bone / Joint XR or aspirate (osteomy/septic A), Send tampon for MCS (TSST)

Non resolving pneumonia: think of other causes ie. Fungal, TB, PE, PH, RHF, drug toxicity, alveolar heaemorrhage etc.

Question 23

Steroids in sepsis

Answer 23

No evidence of benefit unless meningism in meningitis – NEJM Jan 2018 ADRENAL trial

Question 24

Sepsis definition

Answer 24

Sepsis is defined as life-threatening organ dysfunction caused by a dysregulated host response to infection

Suspect if qSOFA>2 [qSOFA = high RR, mental status altered, low SBP]

Question 25

Organ dysfunction definition

Answer 25

Defined as a SOFA score deterioration of 2 or more form baseline

SOFA: PaO2, GCS, MAP, Vasopressor use, sCr, BR< Pl.

Question 26

Septic shock definition

Answer 26

Septic shock is defined as a subset of sepsis in which underlying circulatory and cellular abnormalities substantially increase mortality and risk of organ damage

Characterized by difficulty to maintain SBP>65 despite vasopressor and fluid resuscitation; and lactate>2mmol/L