Lipworth Flashcards
Raised JVP with v waves
Pulmonary hypertension / right heart failure
v waves due to tricuspid regurgitation
Clinical signs of pulmonary hypertension/right heart failure
Central cyanosis if hypoxic
• Dependent oedema
• Raised JVP with V waves (due to secondary tricuspid regurg)
• Right ventricular heave at left parasternal edge
• Murmur of tricuspid regurgitation
• Load P2
• Enlarged liver (pulsatile )
Treatment for Primary Pulmonary Hypertension
Pharmacologic Treatment
- prophylactic anticoagulation [warfarin]
- O2 if hypoxic
- Po Vasodilators :Endothelin antagonist (Oral Bosentan) , PDE5-inhibitor (Oral Sildenafil), iv Epoprostenol
Causes of pulmonary hypertension
Blood clots in the lungs (pulmonary emboli)
Chronic obstructive pulmonary diseases, such as emphysema.
Connective tissue disorders, such as scleroderma or lupus.
Sleep apnea and other sleep disorders.
Heart abnormalities you’re born with (congenital heart defects
What type of respiratory failure follows PE?
• Arterial blood gases-↓PaO2,↓Sao2
Type 1 resp failure:PaCO2 normal or low
Clinical signs of PE
Clinical presentation depends on size:
• Large-cardiovascular shock,low BP,central cyanosis,sudden death
• Medium-pleuritic pain,haemoptysis,breathless
• Small recurrent-progressive dyspnoea, pulmonary hypertension and right heart failure
Diagnosis of PE #1
• Clinical Signs- Tachycardia,Tachypnoea,Cyanosis,Fever Low BP,Crackles, Rub, Pleural effusion
Auscultation of the lungs in PE
Crackles, rub
PE ECG findings
ECG :Acute Rt heart strain pattern (S1,Q3,T3 , T inv in V1-3)
ECG :Acute Rt heart strain pattern (S1,Q3,T3 , T inv in V1-3)
Pulmonary embolism
Diagnosis of pulmonary embolism
• ECG :Acute Rt heart strain pattern (S1,Q3,T3 , T inv in V1-3)
• D-dimers usually raised
• Isotope lung scan (Ventilation/Perfusion)
• Perfusion defect before infarction
• Perfusion+Ventilation matched defect after infarction
CT pulmonary angiogram to image pulmonary artery filling defect
• Leg and pelvic ultrasound to detect silent DVT
• Echocardiogram to measure pulmonary artery pressure and RV size
• Gas transfer factor (TLCO) to measure perfusion defect
• If no obvious underlying cause –eg surgery / pregnancy /malignancy /immobility
• Look for underlying Ca – Clin
exam ,CXR,PSA,CA125,CEA,Pelvic USS
• Autoantibodies (SLE) – Antinuclear ,Anti- Cardiolipin Ab
• Coagulation factor screen – Antithrombin-3,Protein C/S, Factor 5/8
Coagulation factors
Anti-thrombin 3
Protein C/S
Factor 5/8
Prevention of DVT
Early post-op mobilisation
• TED compression stockings
• Calf muscle exercises
• Subcutaneous low dose low mol wt heparin perioperatively
• Dabigatran - direct thrombin inhibitor Rivaroxaban/Apixaban - direct inhibitor of
activated factor Xa- both given orally for prophylaxis of venous thromboembolism in adults after hip or knee replacement surgery
Dabigatran
Direct thrombin inhibitor
Rivaroxaban/Apixaban
Inhibitor of factor Xa
Target range for INR
2.5-3.5
How long should a patient continue with warfarin after PE?
3-6 months (usually at LEAST 5)
lcohol,Antibiotics ,Aspirin,NSAIDs, Amiodarone, Cimetidine,Omeprazole and anticoagulation?
lcohol,Antibiotics ,Aspirin,NSAIDs, Amiodarone, Cimetidine,Omeprazole increase anticoagulation?
Treatment for PE?
Give heparin and continue for 3-5 days (until INR is above 2)
Also give warfarin from the start (as it takes a couple of days to begin to work)
Continue warfarin for at least 5 months
If very bad clot and life threatening e.g. main pulmonary artery occlusion, give thrombolysis (streptokinase or TPA)
How to prevent over-anticoagulation?
Pro-thrombin complex or fresh frozen plasma
Reverse warfarin with VITAMIN K (especially if liver disease!!)
Reverse heparin with protamine
How to reverse heparin?
Protamine
How to reverse warfarin?
Vitamin K
Cromones
e.g. Cromoglycate
Only used in asthma
Mast cell stabiliser
(good in atopic children - exercise induced asthma)
Chlorpheniramine?
First generation anti-histamine, sedative
Omalizumab
Anti-IgE
Injection every 2-4 weeks
Which type of drug do methylxanthines interact with?
P450 drug interactions (erythromycin)
-Methylxanthines have a low therapeutic ratio
Rofumilast
Anti-inflammatory PDE4 inhibitor
Oral tablet, once daily, COPD only
Oral carbocisteine
Erdosteine
Mucolytics
Antibiotics for COPD exacerbation
1st line :Doxyxcycline (covers everything) or Amoxycillin (not cover atypicals)
2nd line : Clarithromycin , Moxifloxacin (also cover atypicals)
Treatment for acute asthma
Oral prednisolone (or iv hydrocortisone )
• Nebulised high dose salbutamol, ± Neb ipratropium, ± iv aminophylline/magnesium
• 60% O2
• ITU Assisted mecahnical intubated ventilation if falling PaO2 and rising PaCO2
- never use respiratory stimulant
Drugs to help you stop smoking?
Nicotine
Bupoprion
Symptoms of COPD
Exertional breathlessness Chronic cough Regular sputum producton Frequent winter 'bronchitis' Wheeze
Drugs that interact with theophylline?
Macrolide and fluoroquinolone antibiotics
Effect of PDE4 inhibitors on FEV1? (e.g. rofumilast)
Effect on FEV1 is miimal, these drugs have an anti-inflammatory action
Which receptor do anti-cholinergics work on?
M3
