Emergencies Flashcards
How are pneumothoraces categorised?
Primary = YOUNG, Spont due to rupture of sub-pleural bleb Secondary = >55YO SMOKERS, Lung pathology
What are the risk factors for a pneumothorax?
Asthma/COPD Infection: TB, pneumonia, lung abscess CT disorder: Marfan's, Ehlers Danlos Trauma/iatrogenic Lung Ca Lung disease: CF, fibrosis, sarcoid
What are the common iatrogenic causes of a pneumothorax?
Pleural aspiration Bronchial biopsy Liver biopsy \+ve pressure ventilation Subclavian CVP line
How does a pneumothorax present?
Asymptomatic Acute progressive dyspnoea Pleuritic chest pain Laboured breathing Tracheal deviation ↓Ipsilateral: Expansion, tactile remits, breath sounds, air entry ↑Ipsilateral: Resonance Pleural rub
How is a pneumothorax investigated?
Determine 1o or 2o
CXR
Bloods: FBC, U&E, Clotting, ABG
ECG: Tachy
Was is classed as a small and a large pneumothorax?
Small = <2cm Large = >2cm
How does a tension pneumothorax occur?
One way valve Continually expanding pneumothorax into pleural space No escape when expiring Mediastinal shift to C/L side Compresses great veins Haemodynamic compromise Cardio-respiratory arrest
How is a tension pneumothorax treated?
O2 15L/min NRB
Needle decompression: 2nd ICS midclav OR triangle of safety
Chest drain in triangle of safety
What are the borders of the triangle of safety?
Ant: Lat border of pec major
Post: Lat border of Lat Dorsi
Inf: 5th rib
How is a primary pneumothorax managed?
> 2cm/SOB: Aspirate 16-18G cannula- aspirate <2.5L. If successful consider discharge + review in 2-4w
NOT successful: Chest drain + admit
<2cm/No SOB: Consider discharge & review in 2-4w
How is a secondary pneumothorax managed?
> 2cm/SOB: Chest drain & admit
1-2cm: Aspirate 16-18G cannula- aspirate <2.5L. If successful (<1cm) = ADMIT (observe for 24hrs) If NOT successful Chest drain & admit
<1cm: ADMIT (observe for 24hrs)
What is the mechanism behind a PE?
Venous thrombi (DVT) dislodges (emboli)
Reaches pulmonary circulation
Unable to fit through & blocks blood flow to lungs
What are the risk factors for a DVT?
Pro-Coag states: COCP, malignancy, nephrotic syndrome
Venous stasis: Immobile, Rx surgery, Pelvic mass, Obesity, Pregnancy/childbirth, Long travel
Miscellaneous: Prev or Fhx of PE/DVT,
Apart from a DVT what other things can cause a PE?
RV thrombus: Post-MI Septic emboli: Tricuspid endocarditis Fat emboli: Long bone # Air emboli: Venous lines, diving Amniotic fluid emboli: Pregnancy
How does a PE present?
Pleuritic chest pain + Dyspnoea = SUDDEN onset Haemoptysis Tachycardia Tachypnoea ↓O2 sats ↑JVP DVT LARGE: Cyanosis, HypoT
How is a PE investigated?
CTPA = DIAGNOSTIC +ve = Heparinise VQ scan ABG: ↓PaO2, ↓PaCO2 = RESP ALKALOSIS ECG CXR: Rarely signs Bloods: APTT, Troponin, D-dimer WELLS Score: >4 = likely Pulm angio = last line
What signs may be seen on ECG to suggest PE?
Sinus Tachy R axis deviation RBBB T wave inversion S1 Q3 T3
What does the Wells Score tell you in ?PE ?
Whether a PE is likely or not:
>4 = Likely → CTPA
<4 = Unlikely → D-Dimer= rule out
What does a D-Dimer tell you in ?PE ?
+ve = may be PE → CTPA/VQ scan
-ve + Wells Score <4 = PE unlikely
Which patients would get a VQ scan over a CTPA?
Allergic to contrast
CKD
How is a haemodynamically stable pt with a PE treated?
O2: 15L/min NRB
LMWH: Tinz 175u/kg OR Fondaparinux OR UFH for 5d
Cardiac monitoring
NSAIDS
What should all people with an ‘unprovoked’ PE get?
Cancer screen!
CT
How is a haemodynamically unstable pt with a PE treated?
500ml NaCl if hypoT
1) Thrombolysis: Alteplase OR Streptokinase
2) Embolectomy if thrombolysis CI
3) IVC filter
How is a patient with a PE anticoagulated?
Confirmed PE = Warfarin OR NOAC Overlap LMWH w/Warfarin or NOAC until INR 2-4 Stop LMWH Provoked = Warfarin for 3m Unprovoked = Warfarin for 6m Continuing RFs (malignancy) = Lifelong
How does a DVT usually present?
Leg discomfort Erythema Swelling Dilated superficial veins Homan's sign: Calf pain of dorsiflexion
How is a DVT investigated?
Wells Score for DVT:
>2 = DVT likely → USS WITHIN 4HRS
<2 = DVT unlikely → D-dimer
USS +ve → refer to DVT team + Anti-coag + Heparinise
USS -ve → D-dimer → +ve = heparinise + redo USS in 1w
How is a DVT treated?
1) LWMH: Tinz sc OR Fondaparinux OR UFH for 5d
2) Warfarin: ALL w/confirmed DVT within 24hrs OR NOAC
Who gets thrombolysis in DVT?
I/L w/Sx ilio-femoral DVT with: -Sx >14d -Good functional status -Low bleed risk -Survival rate >1yr USE: Catheter directed streptokinase
How does a foreign body in the airway cause problems?
Inhalation of foreign body → acute airway obstruction = ↓GCS, Asphyxia → arrest
Who is most likely to have a foreign body obstruction?
Toddlers- small toys, peanuts/food
Elderly
Alcoholics
Recent sedation
How does a mild obstruction present?
Still able to breathe & talk
Effective, loud cough/cry
Fully responsive
How does a severe obstruction present?
Unable to breathe/talk Ineffective cough Stridor Wheezing Cyanosis ↓GCS or unconscious = T2RF
How is choking in a child managed in those with an ineffective cough?
CONSCIOUS: 5back blows → 5 abdo thrusts → assess + repeat
UNCONSCIOUS: Open airway → 5 rescue breaths → CPR 15:2
How does carbon monoxide cause tissue hypoxaemia?
CO has higher affinity for Hb binding than O2
COHb (carboxy-haemoglobin) shifts O2 saturation curve LEFT and DOWN
= Tissue hypoxaemia
What are the signs of CO poisoning?
EARLY: N&V, headache (90%), poor conc/memory
LATE: Dizzy + Vertigo (50%), Cherry red skin, irritable confusion, disorientated, seizure/coma
In CO poisoning typically when does encephalopathy occur?
2-6w after
What are signs of inhalation injury that could lead to CO poisoning?
EARLY INTUBATION Burns to face Soot in nostrils/mouth Stridor/hoarseness/drooling ↓GCS
How is CO poisoning investigated?
Spectrometer = DIAGNOSTIC <10% = common in smokers 10-30% = Symptomatic >30% = Severe ABG: BE AWARE machine reads HbCO as HbO so sats may look normal when not ECG: Myocardial ischaemia (↓ST, VF, VT)
How is CO poisoning treated?
100% O2
Hyperbaric O2
In CO poisoning what are indications of hyperbaric O2 therapy?
LOC
Neuro signs
Pregnancy
MI/arrhythmia
What is the mechanism of ARDS?
Lung damage leads to release of inflammatory mediators
↑permeability of capillaries or loss of oncotic pressure
Leads to ↑Alveolar fluid accumulation
What are the causes of ARDS?
Pulmonary: Pneumonia, gastric aspiration, inhalation, injury, vasculitis, contusion
Other: Post-op, shock, sepsis, DIC, haemorrhage, acute LF, burns, pancreatitis
How does ARDS present?
ACUTE ONSET- within 1w of insult Cyanosis Hypoxia Tachycardia & tachypnoea Peripheral vasoD B/L fine crackles
How is ARDS investigated?
CXR
ABG
Bloods: FBC, LFT, Amylase
How is ARDS managed?
Early intubation = burns or inhalation injury
ICU!!
Oxygenation & ventilation (CPAP)
Vasopressors may be needed
What is the diagnostic criteria for ARDS?
- Acute onset within 1w
- CXR w/ B/L pulmonary infiltrates
- PCWP <19
- Refractory hypoxaemia w/ PaO2:FiO2 <200
