Emergency Medicine/Respiratory Flashcards
1
Q
What does bronchiectasis refer to?
A
Bronchiectasis is a chronic infection of the bronchi and bronchioles leading to permanent dilatation of these airways.
2
Q
What are the main organisms that cause bronchiectasis? (4 bacteria)
A
- H.influenzae
- Strep. pneumoniae
- Staph. aureus
- Pseudomonas aeruginosa
3
Q
What are the congenital causes of bronchiectasis?
A
- Cystic fibrosis
- Primary ciliary diskinesia
- Kartagener’s syndrome
4
Q
What are the post-infective causes of bronchiectasis?
A
- Measles
- Pertussis
- Pneumonia
5
Q
What are the treatments available/what is the management of bronchiectasis? (4)
A
- Postural drainage to remove sputum/mucus
- Antibiotics
- Bronchodilators e.g. nebulised salbutamol
- Surgery
6
Q
In spirometry tests of someone with an obstructive respiratory disease, e.g. COPD or asthma, what would their FEV1/FVC ratio be percentage wise?
A
FEV1 is reduced more than FVC, and the ratio is <75%
7
Q
What is FEV1 and FVC?
A
FEV1 is the forced expiatory volume in 1 second and FVC is forced vital capacity.
8
Q
What is the FEV1/FVC ratio in a healthy individual?
A
Between 75-80%
9
Q
In a patient with a restrictive defect, e.g. lung fibrosis, how is the FVC affected?
A
FVC is reduced, so the FEV1/FVC ratio is either normal or high. So it could be >80%.
10
Q
In addition to pulmonary fibrosis, what are the other restrictive lung conditions? (6)
A
- Sarcoidosis
- Interstitial pneumonias
- Connective tissue diseases
- Pleural effusion
- Obesity
- Kyphoscoliosis
11
Q
Which bacteria is the commonest cause of pneumonia, particularly in alcoholics, the elderly, and immunocompromised patients?
A
Pneumococcal
12
Q
In which people are staphylococcal pneumonias more common?
A
IVDU, young, elderly
13
Q
What are the complications of pneumonia? (6)
A
- Respiratory failure (type 1 is relatively common)
- Hypotension (due to dehydration and vasodilation due to sepsis)
- Atrial fibrillation (common in elderly, usually resolves upon treatment of pneumonia)
- Pleural effusion
- Empyema (should be suspected if a patient with resolved pneumonia develops recurrent fever - aspirated fluid is usually yellow with a pH <7.2)
- Lung abscess
14
Q
There are typically 4 types of lung carcinoma, what are they, in order of prevalence?
A
- Squamous cell (35%)
- Adenocarcinoma (27%)
- Small cell (20%)
- Large cell (10%)
15
Q
What are the most common presenting symptoms of lung carcinoma? (4)
A
- Cough (80%)
- Haemoptysis (70%)
- Dyspnoea (60%)
- Chest pain (40%)
16
Q
What are the less specific symptoms that may present in someone with lung carcinoma? (3)
A
- Anorexia
- Lethargy
- Weight loss
17
Q
What are the signs associated with lung carcinoma? (4)
A
- Cachexia
- Anaemia
- Clubbing
- Palpable supraclavicular/axillary lymph nodes
18
Q
What complications can lung carcinoma without metastasis cause? (5)
A
- Recurrent laryngeal nerve palsy
- Phrenic nerve palsy
- Horner’s syndrome (Pancoast’s tumour)
- Rib erosion
- Pericarditis
19
Q
Why is it important to distinguish between small cell and non-small cell carcinoma of the lung?
A
Their treatment plans are very different and prognosis differs greatly.
20
Q
What is the prognosis for non-small cell lung carcinomas?
A
50% 2 year survival without spread
10% 2 year survival with spread
21
Q
What is the prognosis for small cell lung carcinoma?
A
Median survival is 3 months if untreated, 1-1.5 years if treated
22
Q
What symptoms do people with asthma commonly report? (3)
A
- Dyspnoea
- Cough
- Wheeze
23
Q
What are the three factors that contribute to airway narrowing?
A
- Bronchial muscle contraction
- Mucosal swelling/inflammation
- Increased mucus production
24
Q
What factors are known to trigger asthma/exacerbate it? (8)
A
- Cold air
- Exercise
- Emotion
- Allergens (house dust mites, pollen, fur)
- Infection
- Smoking and passive smoking
- Pollution
- NSAIDs/beta-blockers
25
What % of people with asthma, also have acid reflux?
40-60%
26
What are the signs on examination of asthma?
1. Tachypnoea
2. Audible wheeze
3. Hyperinflated chest
4. Hyperresonant percussion
5. Decreased air entry
6. Widespread, polyphonic wheeze
27
In an acute severe asthma attack, what sign might be seen?
1. Inability to complete sentences
2. Pulse >110bpm
3. RR >25/min
28
In a life-threatening asthma attach, how may someone present?
1. Silent chest
2. Confusion
3. Exhaustion
4. Cyanosis (pO2 <8kPa and O2 % <92%)
5. Bradycardia
29
What would distinguish between life-threatening and near-fatal asthma attack?
pCO2 is elevated (so type 2 respiratory failure due to exhaustion)
30
What is the treatment for chronic asthma? (5 steps)
Step 1 : short-acting inhaled beta2-agonist as required
Step 2 : add standard-dose inhaled steroid e.g. beclometasone
Step 3 : add long-acting beta2-agonist
Step 4 : increase steroid dose up to 2000ug/day
Step 5 : add regular oral prednisolone
31
What is the treatment of acute severe asthma attack? (4)
1. Salbutamol 5mg nebulized with O2
2. Hydrocortisone 100mg IV OR prednisolone 40-50mg PO (or both if very ill)
CALL FOR HELP
3. Add in ipratropium 0.5mg nebulizers
4. Single dose magnesium sulfate IV 1.2-2g
32
What is a thunderclap headache associated with?
Subarachnoid haemorrhage
33
What are the differentials for a unilateral headache with eye pain? (2)
1. Cluster headache
| 2. Acute glaucoma
34
What could cause a cough-initiated headache OR worse in the morning or bending forward? (2)
1. Raised intracranial pressure
| 2. Venous thrombosis
35
What is the main differential for a worsening headache with scalp tenderness in people over 50 years?
Giant cell arteritis
36
What is the main differential for a headache with neck stiffness and/or fever?
Meningitis
37
What are the 5 most common causes for stridor?
1. Foreign body
2. Acute epiglottitis (younger patients)
3. Anaphylaxis
4. Tumour
5. Trauma e.g. laryngeal fracture
38
What are the life-threatening causes of chest pain? (6)
1. Acute MI
2. Angina/acute coronary syndrome
3. Aortic dissection
4. Tension pneumothorax
5. Pulmonary embolism
6. Oesophageal rupture
39
Name the 6 types of shock?
1. Septic shock
2. Anaphylaxis
3. Cardiogenic shock
4. Hypovolaemic shock
5. Haemorrhagic shock
6. Heat exposure
40
Which immunoglobulin is involved in anaphylactic shock?
IgE
41
What is the management of anaphylaxis? (At least 5 steps)
1. Secure airway and give 100% O2
2. Give adrenaline IM 0.5mg - 1:1000 (repeat every 5 minutes if needed)
3. Secure IV accèss and give chlorphenamine and hydrocortisone
4. IVI
5. If wheeze - salbutamol
6. Admit to ICU if necessary
42
What is the initial treatment of an MI? (5 definite)
1. Aspirin 300mg
2. Morphine 5-10mg IV
3. Metoclopramide 10mg IV
4. Oxygen IF sats below <95%
5. GTN ONLY if patient is hypertensive - not routinely recommended in acute setting
6. Restore coronary perfusion - PCI
7. Anticoagulation e.g. clopidogrel or ticagrelor
43
To confirm someone is having an MI, what is the course of action? (2)
1. ECG recording
| 2. Bloods - FBC, U&E, glucose, lipids, cardiac enzymes
44
What is the management plan/treatment plan, for someone having an acute coronary syndrome without ST-elevation? (8)
1. If O2 sats are low <90% or breathless, give low flow O2
2. Morphine + metoclopramide
3. GTN spray or sublingual tablets
4. Aspirin 300mg
5. Oral beta-blocker e.g. metoprolol (if beta-blocker is contraindicated give CCB)
6. Fondaparinux
7. If pain continues give IV nitrate
8. Record ECG while in pain
45
Once a patient has been managed medically for acute coronary syndrome, what investigations/procedures can be carried out?
Angiography with a view to possible PCI or surgery
46
What are the causes of severe pulmonary oedema? (7)
1. Left ventricular failure
2. Valvular heart disease
3. Arrhythmias
4. Malignant hypertension
5. Fluid overload
6. Head injury (neurogenic)
7. Adult respiratory distress syndrome caused by e.g. trauma, malaria, drugs
47
What are the symptoms seen with severe pulmonary oedema? (3)
1. Dyspnoea
2. Orthopnoea
3. Pink frothy sputum
48
What are the signs associated with severe pulmonary oedema? (5)
1. Pale
2. Sweaty
3. Tachycardia
4. Tachypnoea
5. Raised JVP
49
How would pulmonary oedema appear on a CXR? (4)
1. Cardiomegaly
2. Bilateral shadowing
3. Kerley B lines
4. Small effusions at costophrenic angles
50
What is the management of pulmonary oedema/acute heart failure?
1. Sit patient upright
2. Oxygen
3. IV access and monitor ECG
4. Diamorphine
5. Furosemide
6. GTN spray
51
What are the causes of cardiogenic shock? (7)
1. MI
2. Arrhythmias
3. PE
4. Tension pneumothorax
5. Cardiac tamponade
6. Aortic dissection
7. Valve destruction e.g. endocarditis
52
What happens to the heart if there is a cardiac tamponade?
Pericardial fluid collects --> intrapericardial pressure rises --> heart cannot fill --> pumping stops
53
What are the causes of cardiac tamponade? (5)
1. Trauma
2. Lung/breast cancer
3. Pericarditis
4. MI
5. Bacteria e.g. TB
54
What are the signs of cardiac tamponade?
1. Falling BP
2. Rising JVP
3. Muffled heart sounds (Beck's triad)
55
What is the management of cardiac tamponade? (4)
ASK FOR HELP
1. Pericardiocentesis
2. O2
3. Diamorphine
4. Take blood for group and save
56
How may an acute exacerbation of COPD present? (4)
1. Increasing cough
2. Breathlessness
3. Wheeze
4. Decreased exercise capacity
57
What are the differentials for an exacerbation of COPD? (5)
1. Asthma attack
2. Pulmonary oedema
3. PE
4. Anaphylaxis
5. Upper respiratory tract obstruction
58
What is the management of acute COPD? (5)
1. Nebulized bronchodilators - salbutamol and ipratropium
2. Controlled oxygen therapy
3. Steroids - IV hydrocortisone and oral prednisolone
4. Antibiotics - if evidence of infection - amoxicillin or doxycycline
5. IF no response to nebulizers/steroids give IV aminophylline
59
What causes a spontaneous tension pneumothorax in young, thin men?
Rupture of a sub-pleural bulba (a cough may precede it)
60
Which chronic lung diseases can cause tension pneumothorax? (4)
1. Asthma
2. COPD
3. Cystic fibrosis
4. Sarcoidosis
61
Which lung infections can cause tension pneumothorax? (3)
1. TB
2. Pneumonia
3. Lung abscess
62
Which two connective tissue disorders can cause tension pneumothorax?
1. Marfan's syndrome
| 2. Ehlers-Danlos syndrome
63
How can tension pneumothorax present? (2)
1. Sudden onset dyspnoea
| 2. Sudden onset pleuritic chest pain
64
What signs may be seen on examination in someone with a pneumothorax? (2)
1. Reduced expansion, hyper-resonance to percussion
| 2. Diminished breath sounds on affected side
65
What signs may be seen on examination in someone with a tension pneumothorax? (6)
1. Respiratory distress
2. Tachycardia
3. Hypotension
4. Distended neck veins
5. Tracheal deviation away from affected side
6. Reduced air entry/breath sounds on affected side
66
In a suspected tension pneumothorax, what is the treatment? (3 steps)
1. Insert a large-bore (14-16G) needle with a syringe (partially filled with 0.9% saline) into the 2nd intercostal space in the midclavicular line on the affected side. Remove plunger to allow the trapped air to bubble through the syringe until a chest drain can be placed.
2. CXR
3. Then insert a chest drain
67
What is used to calculate the severity of pneumonia?
CURB65
68
What does CURB65 stand for?
```
Confusion
Urea - >7mmol/L
Respiratory rate - >30/min
BP - <90/60mmHg
Age >65
...a score greater than 3 indicates severe pneumonia and should consider ICU referral
```
69
What are the symptoms associated with pneumonia? (9)
1. Fever
2. Rigors
3. Malaise
4. Anorexia
5. Dyspnoea
6. Cough
7. Purulent sputum (classically rusty coloured in pneumococcus)
8. Haemoptysis
9. Pleuritic chest pain
70
What may be the signs on examination in someone with pneumonia? (8)
1. Fever
2. Cyanosis
3. Confusion
4. Tachypnoea
5. Tachycardia
6. Hypotension
7. Signs of consolidation (diminished expansion, dull percussion, increased tactile vocal fremitus)
8. Pleural rub
71
What is the mechanism of diabetic ketoacidosis?
Normally the body metabolises carbohydrates, leading to efficient energy production. Ketoacidosis is an alternative metabolic pathway, normally used in starvation states, it is far less efficient and produces acetone as a by product (hence pear drop breath).
In acute diabetic ketoacidosis, there is excessive glucose but because of the lack of insulin, this cannot be taken up into the cells to be metabolised, so pushing the body into starvation-like state where ketoacidosis is the only mechanism of energy production.
72
How does DKA typically present? (6)
1. Gradual drowsiness
2. Vomiting
3. Dehydration
4. Acidaemia - blood pH <7.3
5. Hyperglycaemia
6. Ketonaemia
73
What vital signs would indicate a severe DKA? (4)
1. O2 sats <92% on air
2. Venous bicarb <5mmol/L
3. Venous/arterial pH <7.1
4. Systolic BP <90mmHg
74
What are the complications of DKA? (4)
1. Cerebral oedema
2. Aspiration pneumonia
3. Hypokalaemia
4. Thromboembolism
75
What is the management plan for DKA?
1. If BP <90mmHg give 500ml bolus saline
2. Do VBG/ABG
3. Insulin - act rapid added to saline bolus
4. Assess need for potassium replacement
5. Check urine output
6. Avoid hypoglycaemia!
7. Continue fixed-rate insulin until ketones <0.3mmol/L
76
What are the signs/symptoms of AKI?
1. Fatigue/malaise
2. Rash
3. Joint pains
4. Nausea/vomiting
5. Chest pain
6. Palpitations
7. SOB
8. Fluid overload
9. Abdominal pain
10. Oliguria
11. Hypo/hyper - tension
77
What is AKI?
It is defined as a rapid reduction in kidney function over hours to days, as measured by serum urea and creatinine, and leading to a failure to maintain fluid, electrolyte and acid-base homeostasis.
78
What is the criteria for diagnosing AKI? (3 different criteria)
Rise in creatinine >26umol/L in 48 hours
or
Rise in creatinine >1.5 x baseline
or
Urine output <0.5mL/kg/h for >6 consec. hours
79
What are the 10 risk factors for developing AKI?
1. Age >75
2. CKD
3. Cardiac failure
4. Peripheral vascular disease
5. Chronic liver disease
6. Diabetes
7. Drugs
8. Sepsis
9. Poor fluid intake/increased losses
10. History of urinary symptoms
80
What is the management of AKI? (5)
1. Urgent ABG/VBG to check potassium (ECG for signs of hyperkalaemia)
2. Treat hyperkalaemia (calcium gluconate, actrapid, glucose)
3. Catheterise to assess hourly urine output
4. Give fluid challenge saline over 30 minutes
5. Reassess
81
What is the treatment for paracetamol poisoning/overdose?
N-acetylcysteine
