Emergency resp Flashcards
What are the features of mod and severe acute asthma?
Mod - PEFR 50-75% w no features of severe asthma
Severe - PEFR 33-50%, RR >25, HR >110, not speaking in full sentences
What are the features of a life threatening asthma exacerbation?
<92%
<33% PEFR
Normal PCO2
Silent chest
Cyanosis
Reduced conc
Hypotension
Poor resp effort and exhaustion
What makes an asthma exacerbation near fatal?
Raised PCO2
What would qualify a patient to w asthma exacerbation to be referred to ITU?
Need ventilatory support
Severe or life threatening asthma not responding to treatment - PEFR reducing, worsening hypoxia, hypercapnia, exhaustion, resp arrest
What is the management of asthma exacerbation?
- 100% O2 non rebreathe mask
- NEB salbutamol 5mg +/- 0.5mg ipratropium
- Hydrocortisone 100mg IV or pred 50mg PO
- NEB salbutamol every 15 mins
- IV 2g Mg sulphate over 20 mins
- IV aminophylline
- ITU
What is the safe discharge of a pt post asthma exacerbation?
PEFR >75%
Stop NEB for 24 hours prior to discharge
Asthma nurse reassess inhaler technique and adherance
5 days prednisolone
GP follow up in 2 days and clinic in 4 weeks
What is the management of COPD exacerbation?
- O2 via venturi mask - O2 sats target depends on ABG
- NEB salbutamol 5mg and ipratropium 0.5 mg
- 100 mg IV hydrocortisone or 50 mg pred PO
- Abx according to local guidelines if sign of infection
What should you consider NIV in COPD?
pH <7.35 or RR >30
BiPAP
When should you consider invasive ventilation in COPD?
pH <7.26
What are some causes of pulm oedema?
Heart failure
ARDS - sepsis, pneumonia, aspiration, severe trauma
Renal artery stenosis
Drug reaction or overdose
PE
High altitude
TRALI
What are the CF of pulm oedema?
Dyspnoea
Anxiety and restlessness - feel like drowning
Frothy sputum
Raised JVP
Peripheral oedema
Crackles
What are the Wells’ criteria for PE?
0-4 = D dimer, if -ve consider work up, if +ve not indicative
>4 = CTPA, PE likely
- Malignancy
- Prev DVT/PE
- Signs of DVT
- Haemoptysis
- Period of immobility
- PE most likely diagnosis
- > 100 BPM
What is the management of pulm oedema?
AtoE - O2 and IV access
Pt upright
IV furosemide 40 mg PO
NIV if medical therapy fails eg. CPAP in ITU
If NIV fails = invasive ventilation and inotropic support in ITU
How do you manage pt w HF and renal fail?
Renal fail due to hypoperfusion, in HF this is caused by more cardiac output.
Diuresis will reduce load on heart and increase cardiac output, increasing renal func.
How do you manage a pt w HF and hypotension?
Risk when using diuretics as don’t want to further reduce BP.
Need to inform senior and consider inotropic support then can attempt small 250ml boluses
Only a temporary measure until definitive therapy can be used
Inotropes vs vaspopressors
(+ve) Inotropes increase myocardial contracility - increasing cardiac output
eg. adrenaline, noradrenaline, dopamine, digoxin
Vasopressors increase vascular resistance - increasing BP
eg. noradrenaline, phenylephrine, dopamine, adrenaline, vasopressin
Both increase perfusion to organs
What are some causes of pneumothorax?
Trauma
Secondary pneumothorax:
Marfan’s and Ehlers-Danlos
COPD and asthma
TB and pneumonia
CF and IPF
Cancer
Primary pneumothorax - tall and thin young male, smoker
What are the CF of pneumothorax?
Sx - sudden pleuritic chest pain and dyspnoea
Signs - affected side = reduced chest expansion, hyperresonant, reduced breath sounds, vocal resonance
Tension = tachy and hypotension, tracheal deviation to unaffected side
What are the ix into pneumothorax?
CXR !!!!!
Other ix to work out underlying cause
What is the management of primary pneumothorax?
<2cm and no SOB = discharge
> 2cm or SOB = first attempt aspiration, if fail = chest drain
CT chest to ix underlying cause
What is the management of secondary pneumothorax?
> 50 and >2cm and SOB = chest drain
If 1-2cm air = aspiration, if aspiration fails = chest drain
<1cm = admit for O2 for 24 hours
Will have CT chest to ix for underlying cause
What is the management of tension pneumothorax?
AtoE - high flow O2 through non rebreathe mask
Open thoracostomy followed by chest drain if possible
Needle decompression w 16 gauge cannula in 4th ICS mix axillary line or 2nd ICS mid clav line ?!??!?*****
What is the risk of recurrence in pneumothorax and how is it managed?
30% risk
Need pleurodesis if recurrence - put talcum powder into pleural space to cause pleura to stick together = no gap for air to go in
Can have a bullectomy if the cause is bullae
What is the advice given when discharging a pt who had a pneumothorax?
Stop smoking
Can’t fly until 7 days after pneumothorax resolved
Avoid scuba diving for life
What are the CF of PE?
- Sudden onset SOB
- Pleuritic chest pain
- Haemoptysis
+/- syncope
O/e - sinus tachy, increased RR, hypoxia, +/- pyrexia, collapse, cyanosis
What is the ix into PE?
CTPA - definitive
What is the management of PE?
LMWH while await CTPA eg. enoxaparin
Once confirmed…
1st line = DOAC eg. rivaroxaban, provoked for 3m, unprovoked = 6m, ongoing cause = for life, eg. coag disorder or cancer
2nd line = LMWH or warfarin
What is massive PE and what is the treatment?
Massive PE = haemodynamic collapse caused by PE, not size on imaging = <90mmHg >15 mins
Need to use IV alteplase (thrombolysis)
Can also - embolectomy if thrombolysis CI, cath thrombolysis, IVC filter = recurrent DVT despite anticoag and anticoag CI
What are the different types of resp failure?
Type 1 - hypoxia without hypercapnia
Type 2 - hypoxia with hypercapnia
What are the CF of pneumonia?
Pyrexia, rigors
Cough
Purulent sputum
Pleuritic chest pain
Haemoptysis
Tachy, increased RR, hypotension, cyanosis, pyrexia, dull percussion, bronchial breathing
What are the common bacteria that cause CAP?
Streptococcus pneumonia
Hamophilus influenzae
Mycoplasma pneumoniae
What increases risk of aspiration pneumonia?
Stroke
MG
Bulbar palsy and ALS
Achalasia
Alcoholism
Emergency intubation
Which side is most likely affected in aspiration pneumonia?
Right lung = R bronchus wide and more vertical
Lying pt - upper lobes
Erect pt - basal segments
What are the ix into pneumonia?
ABG
Bloods - FBC, U+E, LFT, ESR, CRP
Blood culture
Sputum MC+S
CXR
What are the features of pneumonia on CXR?
Infiltrates
Shadowing/opacification
Pleural effusion
Aspiration pneumonia - protean
How do you classify the severity of pneumonia?
CURB65
Confusion
Urea >7
RR >30
BP <90
65+
0-1 = home
2 - admission
3-5 = definite admission +/- ITU
What is the management of pneumonia?
Sepsis 6
Give - IV fluids, IV abx eg. meropenem, O2
Take - lactate, cultures, urine output
Analgeisa
CXR at 6 weeks
What are the CF of aspiration pneumonia?
Chest pain
SOB
Fatigue
Wheezing
Cyanosis
Cough and fever
ARDS
What is the management of aspiration pneumonia?
Abx coverage of gram +ve and gram -ve organisms
eg. IV cephalosporin and IV metronidazole
