Acute respiratory conditions Flashcards
Community-acquired pneumonia.
a) Causes
b) Presentation
c) Management
a) Typical: Pneumococcus, haemophilus influenzae, moraxella, klebsiella (alcoholics, aspiration);
Atypical: chlamydophila, legionella, mycoplasma
b) Resp - Cough (+/- sputum), SOB, pleuritic CP, wheeze
Systemic - fever, rigors, sweats, myalgia
Atypical - diarrhoea, hyponatraemia, lack of focal signs
c) CRB65 0-1:
- manage at home
- Rx: amox/doxy/clari 5 days
- If atypical suspected, add macrolide/dual ABx therapy
- Review inb
CRB 2:
- admit to hospital
- Ix: CXR, bloods, blood and sputum cultures, consider urinary legionella antigen
- Rx: amox + macrolide 7 - 10 days
CRB 3+ :
- consider ITU
- co-amoxiclav + macrolide
CRB-65
a) Give criteria
b) Give guidance
a) Confusion (AMT 8 or less); RR 30 +; BP <90/60 mmHg; Age 65 yrs +
b) 0-1: home care (monotherapy)
2: consider admission (consider dual therapy)
3: urgent admission, consider ITU (co-amox + macrolide)
Common cold.
a) Define
b) Most common organism
c) Common complications
d) Management
a) Mild, self-limiting, viral URTI, characterized by nasal stuffiness and discharge, sneezing, sore throat, and cough
b) Rhinovirus
c) Sinusitis, LRTI, otitis media
d) - Reassurance that it is self-limiting
- Advise fluids and adequate rest. Time off work/school not recommended
- Paracetamol/antipyretics as required (only give if feverish in under 5s)
- OTC remedies may help relieve symptoms in some but there is lack of evidence
Pleural effusions.
a) Causes - two basic types
b) Differentiating these
c) Causes of unilateral pleural effusions
d) Management
a) - Exudative - infection, inflammation, malignancy
- Transudative - CCF, liver failure, nephrotic syndrome
b) Light’s criteria:
- Pleural protein / serum protein > 0.5
- Pleural LDH / serum LDH > 0.6
c) Malignancy, infection
- L-sided: pancreatitis
- R-sided: cholecystitis
d) Treat the cause
Surgical drainage if necessary
PE: indication for thrombolysis
PE with haemodynamic instability (BP < 90 / 60 for 15 minutes despite fluid resuscitation)
Pneumothorax.
a) What is it? - types and risk factors
b) Features (simple vs tension)
a) Collection of air in the pleural cavity, resulting in collapse of the lung on the affected side. Types:
- Primary spontaneous (in healthy people; risk greater in tall and thin patients e.g. Marfans)
- Secondary - due to underlying lung disease (e.g. COPD, asthma, CF, malignancy)
- Traumatic - injury, iatrogenic, ventilator-associated
- Note: smoking increases risk
b) - Symptoms - SOB, pleuritic CP (sudden onset)
- Signs - Increased RR and HR, ipsilateral reduced air entry, reduced chest expansion and hyper-resonance
- Tensioning signs: Contralateral tracheal deviation, distended neck veins, hypoxia, hypotension and reduced consciousness.
Pneumothorax: management
a) Simple pneumothorax
b) Indications for drainage in simple pneumothorax
c) Tension pneumothorax
d) Recurrent pneumothorax
e) Advice for discharge
a) - First, rule out tension
- A-E assessment: give Oxygen
- CXR to diagnose (standard erect film)
- 3 possible courses of action: observe, needle aspiration or chest drain (decision dependent on severity of symptoms and size of pneumothorax)
b) CXR:
- Measure the distance between the pleural surface and the lung edge (at the level of the hilum).
- If 2 cm +, it represents a pneumothorax of at least 50% of the hemithorax and is an indication for drainage
c) - A-E assessment - give oxygen
- URGENT decompression via needle thoracostomy in 2nd ICS midclavicular line or 5th ICS anterior axillary line (gush of air confirms diagnosis)
- Then may require a chest drain
d) - Pleurodesis
- Surgical pleurectomy
e) Safety-netting - further symptoms to return to ED
Pneumothorax: decompression
a) Landmarks
b) Triangle of safety (chest drain)
c) Just above or below rib?
a) - 2nd/3rd ICS midclavicular line (just ABOVE the rib; to miss the neurovascular bundle)
- Or… 4th/5th ICS anterior axillary line
b) - Anterior border of the latissimus dorsi
- Lateral border of the pectoralis major muscle
- Base of the axilla
- 5th ICS
c) ABOVE* rib
* Go above and beyond
Wells’ score for PE
a) Criteria
b) Management based on scores (two-tier model)
c) If deemed PE unlikely on Wells’ score, what other score can be used to rule out PE?
a) - Clinical signs of DVT (3 points)
- PE is #1 diagnosis (3 points)
- Heart rate > 100 (1.5 points)
- Immobilisation for at least 3 days OR surgery in the previous 4 weeks (1.5 points)
- Previous, objectively diagnosed PE or DVT (1.5 points)
- Haemoptysis (1 point)
- Malignancy w/ treatment within 6 months or palliative patient (1 point)
b) 0-4: PE unlikely = high-sensitivity D-dimer test (if neg - ruled out VTE; if pos - do CTPA)
>4: PE likely = CTPA
c) PERC rule
PE: major risk factors
- Previous proven VTE
- Surgery: major abdominal/pelvic surgery, or hip/knee replacement (risk lower if prophylaxis used), postoperative intensive care.
- Lower limb problems: fracture, varicose vein surgery
- Malignancy: abdominal/pelvic, advanced/metastatic.
- Reduced mobility: hospitalisation, institutional care, disability, spinal cord injury.
- Obs/gynae: late pregnancy, puerperium, CS, COCP
- Major trauma
- Central venous lines
- Intravenous (IV) drug use
- Thrombophilias, etc.
PE: clinical features
a) General
b) Massive PE -?
c) Important differentials - cardiac, respiratory, other
a) - Symptoms: SOB, pleuritic CP, haemoptysis, cough, dizziness, syncope
- Signs: tachycardia, tachypnoea, hypoxia, hypotension, signs of RHF, pleural rub, pyrexia
b) Haemodynamic collapse: obstructive shock
c) Cardiac - ACS, Aortic dissection, Tamponade.
Resp - Pneumonia. Pneumothorax. Malignancy
Other - Sepsis.
PE: investigations
a) In all patients - to determine likelihood of PE
b) PE likely
c) PE unlikely
d) If CTPA contraindicated (e.g. severe renal impairment)
e) Patients should also undergo what other tests?
a) Two-level Wells’ score: stratifies into ‘PE likely’ and ‘PE unlikely’
b) Immediate CTPA, or immediate parenteral anticoagulant therapy if CTPA cannot be performed immediately
c) High-sensitivity D-dimer: if negative (excluded), if positive (do CTPA or treat empirically if delay in imaging)
d) V/Q SPECT scan
e) - Bedside: ECG
- Bloods: FBC, CRP, UEs, troponins, clotting
- Imaging: CXR, leg USS if DVT suspected
PE: management
a) Initial
b) Drugs
c) Other options
d) Prognosis score: 30-day mortality
e) Provide patients with what?
a) Resuscitation: A-E (oxygen, IV access, fluids, etc.)
b) - LMWH heparin for 5/7 or until INR > 2 (whichever is longer)
- Warfarin / rivaroxaban for 3/12
c) - Thrombolysis
- Embolectomy
d) Pulmonary Embolism Severity Index (PESI)
e) - Anticoagulant info booklet
- Anticoagulant alert card
VTE prevention.
a) Assume need for VTE prophylaxis in all medical patients who have immobility for how many days?
b) Assume need for VTE prophylaxis in which surgical patients?
c) Preventive measures
d) Contraindications to pharmacological prophylaxis
e) Drugs to be stopped prior to elective surgery
a) 3 days (or anyone with risk factors)
b) Procedures under GA for more than 90 mins (or 60 mins for pelvic or lower limb surgery), immobile for 3 days, acute surgery
c) - Avoid dehydration, encourage early mobilisation
- Mechanical - stockings, pneumatic pressure devices
- Drugs - fondaparinux sodium, LMWH, UFH (in CKD)
d) - Active bleeding, acquired or inherited bleeding disorders, thrombocytopenia, current anticoagulation
- Acute stroke
- LP/epidural/spinal in previous 4h/ expected in next 12h
- Uncontrolled HTN (>230/120)
e) Oestrogens (COCP, HRT) 4 weeks prior
Antiplatelets - balance risks vs benefits (1 week prior)
Acute pulmonary oedema: management
a) Drugs + administration
b) Adjuvant therapies
a) - IV diuretic ( furosemide 40 - 80 mg, given slowly).
- IV opioid (diamorphine 2.5 - 5.0 mg, slow over 5 mins)
- IV anti-emetic (for example metoclopramide 10 mg).
- Nitrate, either sublingually or buccally (for example GTN spray, two puffs).
b) - Oxygen
- CPAP, BiPAP, invasive ventilation
