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4th Year ACC > Breathlessness > Flashcards

Breathlessness Flashcards

1
Q

Cardiac signs of a PE

A

Low BP

High HR

Gallop rhythm

High JVP

RV heave

Cyanosis

AF

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2
Q

Resp sx/signs of a PE

A

Pleural rub and pleuritic pain

Tachypnoea

Cyanosis

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3
Q

What are the scoring tests and algorithm for PE

A

Well’s score:

<4 do d-dimer- negative can rule out, positive do CTPA

> 4 straight to CTPA (or if a delay treat with LMWH)

Low risk- PERC score to rule out

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4
Q

Further investigations in PE

A

CXR

ABG

U&E, FBC, clotting

ECG

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5
Q

What can you use if CTPA unavailable for PE?

A

V/Q scan

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6
Q

What can you use the if susp PE patient is well and the CXR is normal

A

V/Q scan

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7
Q

Management of PE

A

Morphine 5-10mg IV

LMWH or fondaparinux (IV)

Thrombolysis (e.g. alteplase) if haemodynamically stable,
if they are not then consider vasopressors

Anticoags for long term- DOAC or warfarin

Consider the cause

O2 and fluids if needed

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8
Q

If hypotensive/haemodynamically unstable patient with PE who do you need for input?

A

ICU

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9
Q

How do you switch from the LMWH to the longer term anticoag for PE?

A

If DOAC, swap. If warfarin, do both and stop the LMWH when the INR is <2

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10
Q

What causes could there be of PE?

A

DVT, malignancy, thrombophilia, polycythaemia, OCP, pregnancy, immobility.

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11
Q

How long does someone with a PE need to remain on their anticoagulant?

A

Depends:

Provoked PE: 3m then reassess

Unprovoked PE: >3 months

Malignany: 6m or until cancer gone

Pregnancy: until end of pregnancy.

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12
Q

Negative PERC score change of PE?

A

2%

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13
Q

What might the CXR show in PE?

A

decreased vascular markings, wedge shaped infarct

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14
Q

What might the ECG show in PE?

A

often normal or sinus tachycardia

May have:

RBBB

AF

RA deviation

S1Q3T3

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15
Q

What is S1Q3T3?

A

S wave in lead 1 is deep

Q wave present in lead 3

T wave inverted in lead 3

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16
Q

4 causes pulmonary oedema

A

Cardiac

ARDS

Fluid overload

Neurogenic

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17
Q

Symptoms pulmonary oedema

A

Dyspnoea, orthopnoea, pink frothy sputum

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18
Q

Examination findings in pulmonary oedema

A

Raised JVP

Fine crackles

Gallop rhythm

Wheeze

Usually sitting up and leaning forward, distressed, pale, sweaty

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19
Q

Investigations to get in susp pulmonary oedema

A

CXR

ECG

U&E, troponin, ABG, BNP

Possibly an echo

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20
Q

What does CXR pulmonary oedema show?

A

Alveolar oedema

B-lines (kerly)

Cardiomegaly

Diversion of upper lobes (blood vessel dilation)

Effusions bilaterally

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21
Q

What are you looking for in pulmonary oedema ecg?

A

MI

dysrhthmia

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22
Q

Management of pulmonary oedema

A

Sit up right

High flow O2

IV access and monitor ECG, treat arrhythmias

Diamorphine 1.25-5mg IV slowly

Furosemide 40-80mg IV slowly

GTN 2 puffs (unless sys BP <90), if systolic BP >/= 100 start nitrate infusion

Observe on cardiac monitor/telemetry

Daily weighing and repeat CXR

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23
Q

What would you do if pulmonary oedema is worsening further following initial management?

A

A further 40-80mg furosemide.

Consider CPAP

Increase nitrate if able to without dropping BP

Consider alt diagnosis

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24
Q

If someone with pulmonary oedema has systolic BP <100 how do you treat it?

A

Treat as cardiogenic shock and send to ICU

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25
Q

How much do you want the weight to decrease by each day in pulmonary oedema?

A

0.5kg/day

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26
Q

60-75% pneumonias are caused by ___?

A

Strep pneumoniae

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27
Q

Staph aureus is a more common cause of pneumonia in which group?

A

ICU pts

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28
Q

Four other common pathogen causes of pneumonia

A

Viruses

Haemophilus influenzae, m. pneumoniae, legionella, chlamydia psittaci

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29
Q

What pathogen is likely to cause pneumonia in HAP, immunocompromised and COPD

A

Pseudomonas

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30
Q

15% pneumonia is caused by _____

A

viruses e.g. influenza

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31
Q

What four signs might you notice in pneumonia

A

Dull percussion note

Increased tactile vocal f/r

Bronchial breathing

Pleural rub

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32
Q

What investigations do you do initially for pneumonia

A

CURB 65 score

CXR

SpO2 ± ABG

FBC, U&E, LFT, CRP

Consider viral throat swab and mycoplasma PCR/serology

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33
Q

What does each bit of CURB 65 stand for?

A

confusion (AMTS <8)

Urea (>7mmol/L)

Resp rate (30+/min)

BP (<90/60)

> 65yo

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34
Q

How do you interpret the CURB score

A

0-1 home Rx

> 2 hospital

3+ severe, to ICU

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35
Q

If CURB is >2 what further investigations do you do?

A

Blood cultures, IV antibiotics (PO if <2), urine pneumococcal and legionella urine antigens, sputum cultures

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36
Q

Management of pneumonia

A

ABC- Oxygen, fluids if needed

Antibiotics - depends on CURB and guidelines

Analgesia

If hypoxic on O2- ventilator/CPAP

37
Q

What antibiotics are generally given

A

CURB 0-1- amoxicillin/clarithromycin/doxycycline

2- amox and clarithro or doxy

3- co-amox or cephalosporin AND clarithro (all IV)

38
Q

Hospital acquired pneumonia is more likely to be caused by which three types of organism?

A

Gram -ve bacilli

Pseudomonas

Anaerobes

39
Q

Antibiotics generally for HAP?

A

Aminoglycoside + antipseudomonal penicillin or 3rd gen ceph (all IV)

40
Q

Is there a diagnostic test for asthma?

A

No, tests just influence probability

41
Q

What is classed as moderate acute asthma?

A

PEF >50-75% best/predicted

42
Q

What makes acute asthma acute severe?

A

Any one of:

  1. PEF 33-50% best/predicted
  2. Resp rate >/=25
  3. HR >/=110
  4. Unable to complete sentences in 1 breath
43
Q

What makes asthma life-threatening?

A

Severe + any one of:

  1. PEF <33% best/predicted
  2. SpO2 <92%
  3. PaO2 <8kPa
  4. Normal PaCO2 (4.6-6)
  5. Silent chest
  6. Cyanosis
  7. Poor respiratory effort
  8. Arrythmia
  9. Exhaustion
  10. Altered conscious level
  11. Hypotension
44
Q

What makes acute asthma ‘near fatal’?

A

PaCO2 raised and/or requiring mechanical ventilation with raised inflation pressures

45
Q

Which asthma patients require ABG?

A

SpO2 <92% or other features of life-threatening

Or not responding when should be or deteroirating

46
Q

Do you CXR acute asthma?

A

If life threatening, not responding or require ventilation

47
Q

Which asthma patients should be admitted

A
  • Any feature of life threatening or near-fatal
  • Any feature of acute severe persisting after initial treatment

If their PEF is >75% best/predicted after 1 hour of treatment they may be discharged from the ED (unless other reasons why admission might be appropriate).

48
Q

What is the mnemonic for asthma management?

A

OSHITME

49
Q

What O2 sats should you aim for in asthma

A

94-98%

50
Q

if you don’t have a sats probe should you still give oxygen in acute asthma?

A

Yes don’t delay, but commence monitoring as soon as available

51
Q

What is the first line treatment for acute asthma?

A

B2 agonist (salbutamol) ASAP

52
Q

What route should the salbutamol be given by and what dose for acute asthma?

A

In moderate and acute severe:

  • inhaler.
  • 2-10 puffs every 10-20 mins or PRN (each puff is 100 micrograms)

In life threatening, or in refractory:

  • nebulised (O2 driven)
  • 5mg every 20-30 minutes or PRN
53
Q

Which acute asthma patients should receive steroids? Which one, dose etc?

A

All of them

Prednisolone PO 40–50 mg daily for at least 5 days or until recovery.

54
Q

What is an alternative steroid for acute asthma if can’t swallow?

A

Hydrocort IV

55
Q

When should you add ipratropium bromide to Rx in acute asthma?

A

-Acute severe or life threatening

OR

-poor response to initial salbutamol

56
Q

Dose of Ipratropium bromide in acute asthma?

A

0.5mg 4-6 hourly nebulised (add to the nebuliser as well as salbutamol)

57
Q

Is nebulised mgso4 recommended in acute asthma?

A

No

58
Q

When would you consider giving magnesium in acute asthma?

A

In acute severe that has not had good initial response to salbutamol

Need consultation with senior

59
Q

Magnesium sulphate route and dose in acute asthma?

A

IV infusion over 20 mins

1.2-2g

60
Q

What is the E in OSHITME?

A

Escalate

61
Q

Which acute asthma patients should be referred to intensive care?

A
  • require ventilatory support
  • acute severe or life-threatening that is failing to respond (evidenced by deteriorating PEF, persisting or worsening hypoxia, hypercapnia, ABG analysis showing decreasing pH, exhaustion, drowsy, confused, altered consciousness poor respiratory effort or respiratory arrest.)
62
Q

How should asthma attack be followed up?

A

Inform GP within 24hr

Near fatal- specialist supervision indefinitely

Severe- f/u by respiratory for at least 1y.

63
Q

What investigations would you do in someone who presented with acute asthma?

A

PEFR

SpO2

ABG- IF spo2 <92% or life-threatening

Resp examination

64
Q

What is a mnemonic to remember things to ask in breathlessness history?

A

ONE RESP

Onset

Nature

Exercise tolerance

Relieving

Exacerbating

Sleep

Pillows

65
Q

Investigations to do for infective exacerbation COPD

A

ABG

CXR (r/o pneumothorax and pneumonia)

FBC, U&E, CRP

ECG

Temperature

Sputum microscopy and culture if purulent

Blood culture if pyrexial

66
Q

What should you ask the patient early in an acute exacerbation COPD

A

Wishes on ICU and ventilation

67
Q

Basic management steps in acute exacerbation COPD

A

Oxygen (if SpO2 <88% or PaO2 <7kpa)

Bronchodilators

Steroids

Antibiotics if indicated

Physio

68
Q

Which management can you start immediately before needing to do ABGs, CXR

A

Bronchodilators

69
Q

How do you give O2 therapy in acute exacerbation COPD

A

Start at 24-28% FiO2 and aim for 88-92% SpO2

Get an immediate ABG and then titrate the FiO2 with serial ABGs to find the minimum FiO2 that will give clinical improvement, without resulting in hypercapnia or acidosis.

Aim for PaO2 >8kpa with a rise in PaCO2 <1.5kpa

70
Q

What bronchodilator should you give in acute exacerbation COPD?

A

Nebulised salbutamol 5mg/4hr

Consider adding ipratropium 0.5mg/6h

71
Q

Should the nebuliser be O2 driven in acute exacerbation COPD?

A

Yes unless they are known to be a hypercapnoeic, acidotic COPD patient in which case you use compressed air to drive the neb, and supplement with nasal prong O2 1-4L

72
Q

What steroids do you give in acute exacerbation COPD?

A

Oral prednisolone 30mg PO stat (and then OD for 7-14 days)

Or IV hydrocortisone 100mg

73
Q

When do you give antibiotics in acute exacerbation COPD and what?

A

If evidence of infection

E.g. amoxicillin 500mg TDS PO

74
Q

What is physio for in COPD?

A

Aid expectoration

75
Q

What could you do if no response to initial treatment in acute exacerbation COPD?

A

IV aminophylline

76
Q

What would you do if IV aminophylline didn’t work in an acute exacerbation COPD?

A

non invasive ventilation (NIPPV) if no response and:

RR >30

pH <7.35

PaCO2 raised

Or becoming increasingly exhausted/agitated/confused

77
Q

Contraindications to NIPPV in acute exacerbation COPD?

A

apoea

pneumothorax

severe agitation

inability to tolerate or fit the face mask

78
Q

What could you do in acute exacerbation COPD if NIPVV didn’t work?

A

ONLY IF APPROPRIATE FOR THE PATIENT (level of function etc)

Intubation and ventilation (pH <7.26 and PaCO2 rising)

79
Q

If can’t do peak flow how do you estimate?

A

Height and gender

Or ask them what is normal

80
Q

What is a side effect of prednisolone that might make you want to give hydrocort IV instead?

A

Prednisolone makes you want to vomit

81
Q

How long does it take for steroids to work in asthma?

A

6-12hr

82
Q

Do IV steroids work quicker than PO in asthma?

A

No

83
Q

Do you have to check magnesium levels before giving it in asthma?

A

No

84
Q

When do you give bipap in copd?

A

resp acidosis

tried medical therapy for an hour

85
Q

What do you need to do before bipap in copd?

A

CXR to check for pneumothorax

86
Q

Infective resp symptoms, IVDU and drop sats on exertion suggests what pathogen of pneumonia?

A

Pneumocystis jiroveci

87
Q

Pneumonia pathogen in long term ventilator

A

Staph aureus

88
Q

Coming back from week in Spain pneumonia pathogen?

A

Legionella

89
Q

pneumonia pathogen in alcoholic and diabetic

A

Klebsiella

4th Year ACC (9 decks)

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