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Yr 5 Respiratory > Emergencies > Flashcards

Emergencies Flashcards

1
Q

How are pneumothoraces categorised?

A 
Primary = YOUNG, Spont due to rupture of sub-pleural bleb
Secondary = >55YO SMOKERS, Lung pathology
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2
Q

What are the risk factors for a pneumothorax?

A 
Asthma/COPD
Infection: TB, pneumonia, lung abscess
CT disorder: Marfan's, Ehlers Danlos
Trauma/iatrogenic
Lung Ca
Lung disease: CF, fibrosis, sarcoid
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3
Q

What are the common iatrogenic causes of a pneumothorax?

A 
Pleural aspiration
Bronchial biopsy
Liver biopsy
\+ve pressure ventilation
Subclavian CVP line
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4
Q

How does a pneumothorax present?

A 
Asymptomatic
Acute progressive dyspnoea
Pleuritic chest pain
Laboured breathing
Tracheal deviation
↓Ipsilateral: Expansion, tactile remits, breath sounds, air entry
↑Ipsilateral: Resonance 
Pleural rub
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5
Q

How is a pneumothorax investigated?

A

Determine 1o or 2o
CXR
Bloods: FBC, U&E, Clotting, ABG
ECG: Tachy

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6
Q

Was is classed as a small and a large pneumothorax?

A 
Small = <2cm
Large = >2cm
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7
Q

How does a tension pneumothorax occur?

A 
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
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8
Q

How is a tension pneumothorax treated?

A

O2 15L/min NRB
Needle decompression: 2nd ICS midclav OR triangle of safety
Chest drain in triangle of safety

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9
Q

What are the borders of the triangle of safety?

A

Ant: Lat border of pec major
Post: Lat border of Lat Dorsi
Inf: 5th rib

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10
Q

How is a primary pneumothorax managed?

A

> 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

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11
Q

How is a secondary pneumothorax managed?

A

> 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)

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12
Q

What is the mechanism behind a PE?

A

Venous thrombi (DVT) dislodges (emboli)
Reaches pulmonary circulation
Unable to fit through & blocks blood flow to lungs

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13
Q

What are the risk factors for a DVT?

A

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,

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14
Q

Apart from a DVT what other things can cause a PE?

A 
RV thrombus: Post-MI
Septic emboli: Tricuspid endocarditis
Fat emboli: Long bone #
Air emboli: Venous lines, diving
Amniotic fluid emboli: Pregnancy
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15
Q

How does a PE present?

A 
Pleuritic chest pain + Dyspnoea = SUDDEN onset
Haemoptysis
Tachycardia
Tachypnoea
↓O2 sats
↑JVP 
DVT
LARGE: Cyanosis, HypoT
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16
Q

How is a PE investigated?

A 
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
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17
Q

What signs may be seen on ECG to suggest PE?

A 
Sinus Tachy
R axis deviation
RBBB
T wave inversion
S1 Q3 T3
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18
Q

What does the Wells Score tell you in ?PE ?

A

Whether a PE is likely or not:
>4 = Likely → CTPA
<4 = Unlikely → D-Dimer= rule out

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19
Q

What does a D-Dimer tell you in ?PE ?

A

+ve = may be PE → CTPA/VQ scan

-ve + Wells Score <4 = PE unlikely

20
Q

Which patients would get a VQ scan over a CTPA?

A

Allergic to contrast

CKD

21
Q

How is a haemodynamically stable pt with a PE treated?

A

O2: 15L/min NRB
LMWH: Tinz 175u/kg OR Fondaparinux OR UFH for 5d
Cardiac monitoring
NSAIDS

22
Q

What should all people with an ‘unprovoked’ PE get?

A

Cancer screen!

CT

23
Q

How is a haemodynamically unstable pt with a PE treated?

A

500ml NaCl if hypoT

1) Thrombolysis: Alteplase OR Streptokinase
2) Embolectomy if thrombolysis CI
3) IVC filter

24
Q

How is a patient with a PE anticoagulated?

A 
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
25
Q

How does a DVT usually present?

A 
Leg discomfort
Erythema 
Swelling
Dilated superficial veins
Homan's sign: Calf pain of dorsiflexion
26
Q

How is a DVT investigated?

A

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

27
Q

How is a DVT treated?

A

1) LWMH: Tinz sc OR Fondaparinux OR UFH for 5d

2) Warfarin: ALL w/confirmed DVT within 24hrs OR NOAC

28
Q

Who gets thrombolysis in DVT?

A 
I/L w/Sx ilio-femoral DVT with:
-Sx >14d
-Good functional status
-Low bleed risk
-Survival rate >1yr
USE: Catheter directed streptokinase
29
Q

How does a foreign body in the airway cause problems?

A

Inhalation of foreign body → acute airway obstruction = ↓GCS, Asphyxia → arrest

30
Q

Who is most likely to have a foreign body obstruction?

A

Toddlers- small toys, peanuts/food
Elderly
Alcoholics
Recent sedation

31
Q

How does a mild obstruction present?

A

Still able to breathe & talk
Effective, loud cough/cry
Fully responsive

32
Q

How does a severe obstruction present?

A 
Unable to breathe/talk
Ineffective cough
Stridor
Wheezing
Cyanosis
↓GCS or unconscious = T2RF
33
Q

How is choking in a child managed in those with an ineffective cough?

A

CONSCIOUS: 5back blows → 5 abdo thrusts → assess + repeat
UNCONSCIOUS: Open airway → 5 rescue breaths → CPR 15:2

34
Q

How does carbon monoxide cause tissue hypoxaemia?

A

CO has higher affinity for Hb binding than O2
COHb (carboxy-haemoglobin) shifts O2 saturation curve LEFT and DOWN
= Tissue hypoxaemia

35
Q

What are the signs of CO poisoning?

A

EARLY: N&V, headache (90%), poor conc/memory
LATE: Dizzy + Vertigo (50%), Cherry red skin, irritable confusion, disorientated, seizure/coma

36
Q

In CO poisoning typically when does encephalopathy occur?

A

2-6w after

37
Q

What are signs of inhalation injury that could lead to CO poisoning?

A 
EARLY INTUBATION
Burns to face
Soot in nostrils/mouth
Stridor/hoarseness/drooling
↓GCS
38
Q

How is CO poisoning investigated?

A 
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)
39
Q

How is CO poisoning treated?

A

100% O2

Hyperbaric O2

40
Q

In CO poisoning what are indications of hyperbaric O2 therapy?

A

LOC
Neuro signs
Pregnancy
MI/arrhythmia

41
Q

What is the mechanism of ARDS?

A

Lung damage leads to release of inflammatory mediators
↑permeability of capillaries or loss of oncotic pressure
Leads to ↑Alveolar fluid accumulation

42
Q

What are the causes of ARDS?

A

Pulmonary: Pneumonia, gastric aspiration, inhalation, injury, vasculitis, contusion
Other: Post-op, shock, sepsis, DIC, haemorrhage, acute LF, burns, pancreatitis

43
Q

How does ARDS present?

A 
ACUTE ONSET- within 1w of insult
Cyanosis
Hypoxia
Tachycardia &amp; tachypnoea
Peripheral vasoD
B/L fine crackles
44
Q

How is ARDS investigated?

A

CXR
ABG
Bloods: FBC, LFT, Amylase

45
Q

How is ARDS managed?

A

Early intubation = burns or inhalation injury
ICU!!
Oxygenation & ventilation (CPAP)
Vasopressors may be needed

46
Q

What is the diagnostic criteria for ARDS?

A
  1. Acute onset within 1w
  2. CXR w/ B/L pulmonary infiltrates
  3. PCWP <19
  4. Refractory hypoxaemia w/ PaO2:FiO2 <200

Yr 5 Respiratory (6 decks)

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