MedED acute resp Flashcards
what type of resp tract infection is pneumonia?
lower
what is a HAP?
a pneumonia that occurs 48 hrs after hospital admission
how long after admission to hospital does HAP occur?
48 hrs or more
what are the 3 common organisms for CAP?
strep pneumoniae
mycoplasma pneumoniae
heamophilius pneumoniae
what are the 3 common organisms for HAP?
staph aureus
pseudomonas aerunginosa
klebsiella
what are the 4 common organisms for atypical pneumonia?
mycolpasma pneumoniae
legionella pneumoniae
chlamydia psittaci
chalmydia pneumoniae
what is the most common organism for CAP?
strep pneumoniae
in what patients is there a higher risk of aspiration pneumonia?
stroke
what are rf for pneumonia?
smoking
recent travel
immunocompromised
what pneumonia is associated with faulty air con?
legionella
what pneumonia is associated with pet birds?
chlamydia psittaci
what is chlamydia psittaci pneumonia associated with?
keeping pet birds
what is legionella pneumonia associated with?
faulty air con- hotels, offices etc
what are typical symptoms of pneumonia?
high fever
SOB
productive cough (usually green or yellow sputum)
pleuritic chest pain
what are atypical symptoms of pneumonia?
dry cough headache diarrhoea myalgia hepatitis confusion
what pneumonia organism is associated with confusion?
legionella
what are examination findings in pneumonia?
resp distress cyanosis reduced chest expansion dull percussion basal coarse crepitations (walking on snow) bronchial breathing increased vocal resonance
what is heard on auscultation in pneumonia and describe what any of it sounds like
basal coarse crepitations- sounds like walking on snow
increased vocal resonance
bronchial breathing
what are atypical examination signs in pneumonia?
mycoplasma pneumoniae: transverse myelitis (inflammation of spinal chord), erythema multiforme (round lesions with bullseye appearance), autoimmune haemolytic anaemia
legionella: hyponatraemia, abnormal LFTs
what are atypical examination signs in mycoplasma pneumonia? explain how they look/arise
transverse myelitis (inflammation of spinal chord)- will give neuro symptoms erythema multiforme (round lesions with bullseye appearance) autoimmune haemolytic anaemia- SOB, fatigue
what are atypical examination signs in legionella pneumonia? explain how they look/arise
hyponatraemia
abnormal LFTs
in what pneumonia might you get transverse myelitis, eyrthema multiforme and autoimmune haemolytic anaemia?
mycoplasma pneumoniae
in what pneumonia might you get abnormal LFTs and hyponatraemia?
legionella
what ix are done for pneumonia?
bedside: sputum MCS
bloods: FBC (high WCC), high CRP, type 1 resp failure on ABG
imaging: CXR (consolidation with fluid level)
what investigations are done for atypical pneumonia? what will you see
mycoplasma: blood film (will show red cell agglutination with cold agglutinin)
legionella: has urinary antigens and abnormal LFTs
what investigation might you do for mycolpasma pneumoniae and what will you see?
do a blood film, you will see red cell agglutination with cold agglutinin
what will you see in CXR in pneumonia?
lobar pneumonia- consolidation in one lobe
bronchopneumonia- consolidation all over the lungs
how do you manage pneumonia?
CURB 65
what does CURB65 stand for and what is needed for a point in each catagory?
confusion- AMTS 8 or less urea- >7 mmol/L resp rate- >30 BP- systolic <90 age- over 65
what is needed to get a point for confusion in CURB65?
AMTS score 8 or under
what is needed to get a point for urea in CURB65?
> 7 mmol/L
what is needed to get a point for resp rate in CURB65?
higher than 30
what is needed to get a point for BP in CURB65?
systolic under 90 mmHg
what is needed to get a point for age in CURB65?
over 65
if CURB 65 score is 1 how is pnuemonia managed?
GP and oral abx
if CURB 65 score is 2 how is pnuemonia managed?
A&E + IV abx
if CURB 65 score is 3 or more how is pnuemonia managed?
hospital admission, IV abx and consider ITU
what abx are used to treat typical pneumonia?
amoxicillin
co amoxiclav if severe
what abx are used to treat atypical pneumonia?
clarithromycin
what abx are given if the causative organism of pneumonia is not known and why?
amoxicillin- covers typical organisms
clarithromycin- covers atypical organisms
what does AMT stand for?
abbreviated mental test score
what abx is given in pneumonia if they are allergic to penicllin?
doxycycline
what abx is given for pneumocystitis jiroveci?
co trimoxazole (trimethoprim and sulfamethoxazole)
what pneumonia is associated with HIV?
pneumocystis jiroveci
what is pneumocystis jiroveci associated with?
HIV
what type of infection is acute bronchitis usually?
viral
what are some typical organisms for acute bronchitis?
rhinovirus parainfluenza influenza a or b respiratory syncytial virus coronavirus
what type of resp tract infection is acute bronchitis?
upper
what are rf for acute bronchitis?
smoking
cystic fibrosis and copd (anything that impairs airway clearance)
what are symptoms of acute bronchitis?
dry or minimally productive cough
SOB
wheeze
mild fever
how does fever differ in acute bronchitis vs pneumonia?
acute bronchitis= low fever
pneumonia= high fever
what type of fever do you get in pnuemonia?
high
what type of fever do you get in acute bronchitis?
low
how is acute bronchitis diagnosed?
usually clinically based on presentation and hx and exam
is CXR needed in acute bronchitis?
no, but might do
how is acute bronchitis managed?
paracetamol and ibuprofen as needed
bedrest
hydration
if cough is present >2 weeks= inhaled ICS
if they have underlying lung pathology eg copd/asthma oral abx (amoxicillin for 7 days or doxycycline if penicillin allergy for 7 days)
how is management of acute bronchitis different if the patient is healthy, if their cough has lasted over 2 weeks and if they have underlying lung pathology?
healthy= paracetamol/ibuprofen, hydration, bed rest
cough over 2 weeks= inhaled ICS
underlying lung pathology= amoxicillin 7 days or if allergic to penicillin doxycycline
where is an embolus formed and where does it get lodged in a PE?
clot is formed in the veins
clot is lodged in the pulmonary arterial system
what are rf for PE?
OCP
pregnancy
what do you ask a radiologist for in PE?
CTPA
what are symptoms of PE?
pleuritic chest pain
SOB
collapse if severe
what is an acute massive PE?
sudden complete occlusion of a pulmonary artery
what is an acute small PE?
sudden incomplete occlusion of a pulmonary artery
what is a chronic PE?
chronic occlusion of pulmonary microvasculature
how does chronic PE present?
exertional dyspnoea
in what type of PE might you get haemoptysis?
acute small PE
what is seen on ECG in PE?
S1Q3T3
right axis deviation
right bundle branch block
sinus tachycardia
what happens of HR in PE?
it increases
what is a buzzword for PE?
s1q3t3
what is seen on CXR in PE?
westermark’s sign
what is westermarks sign seen in?
PE on a CXR
what is seen in s1q3t3?
s wave in lead 1 (the s point on the ECG is deep and negative)
q wave in lead 3
inverted t waves in lead 3
what score is used to determine the risk of a PE?
well’s score
what is done after calculating well’s score?
if its 4 or over order a CTPA
if its under 4 order a d dimer
in PE when do you do a CTPA and when do you do a d dimer?
if wells score is 4 or above do a CTPA
if wells score is under 4 do a d dimer
how is PE managed?
if they are haemodynamically stable: respiratory support and anticoagulation (fondaparinux first line/heparin for 5 days or warfarin for 3 months)
if they are haemodynamically unstable: first line thrombolysis (alteplase first line/ streptokinase/ rt-PA) and second line surgery embolectomy
how is haemodynamically stable PE managed? give specific drug names and courses?
respiratory support
anticoagulation- fondaparinux or heparin for 5 days OR warfarin for 3 months
what drugs are used to anticoagulate someone with haemodynamically stable PE and how long are they given for?
fondaparinux or heparin for 5 days
warfarin for 3 months
how is haemodynamically unstable PE managed?
IV thrombolysis- first line alteplase, can also use streptokinase or rt-PA
second line embolectomy
according to NICE guidelines who needs a VTE risk assessment in hospital and when is it done?
everyone needs one within 24h of admission
how is VTE risk assessment done? how do you remember this?
TEDs and tinz
mechanical= TED compression stockings
pharmacological= LMWH tinzaparin
what is TEDs and tinz used to remember?
how to do VTE risk assessment
mechanical= TED compression stockings
pharmacological= LMWH tinzaparin
how is LMWH given?
subcut injection
in what space does air collect in a pneumothorax?
pleural space
what is the difference between a traumatic and spontaneous penumothorax?
traumatic= damage to parietal pleura spontaneous= damage to visceral pleura
what pneumothorax is associated with damage to parietal vs visceral pleural?
parietal= traumatic visceral= spontaneous
out of the parietal and visceral pleura which is closer to the lung and how do you remember this?
visceral in innermost and closer to the lung
when you have a ‘visceral reaction’ its intense so that one most be closer
the gap between what is the pleural space?
parietal and visceral pleura
what is primary v secondary pneumothorax?
primary= young and otherwise healthy patient secondary= existing lung pathology eg copd
what are rf for pneumothorax?
smoking
male
marfans syndrome
how is primary pneumothorax managed?
if they are not SOB or <2cm discharge and ODP review
if >2cm or SOB perform needle aspiration
if needle aspiration works then observe and give o2
if needle aspiration doesnt work then insert a chest drain
how is secondary pneumothorax managed?
if its >2cm or they are SOB insert a chest drain
if its <1cm observe and give o2
if its between 1cm and 2cm needle aspiration then observe and o2
if between 1cm and 2cm and needle aspiration doesnt work insert a chest drain
when is a chest drain used to manage a pneumothorax?
if they have a primary pneumothorax >2cm or are SOB and needle aspiration doesn’t work
if they have a secondary pneumothorax >2cm or are SOB chest drain straight away
if they have a secondary pneumothorax 1cm-2cm and fine needle aspiration isnt sucessful
when is fine needle aspiration used to manage a pneumothorax?
if they have a primary pneumothorax >2cm or are SOB first line
if they have a secondary pneumothorax 1cm-2cm first line
when can you discharge someone as management for a pneumothorax?
if they have a primary pneumothorax <2cm and they arent SOB
what happens in a tension pneumothorax?
everytime the patient breathes in more and more air gets trapped in the lungs till eventually there is so much air in the lungs that the trachea deviates and theres a mediastinum shift
where does the trachea deviate in tension pneumothorax and how do you remember?
away from the side
remember by thinking about what happens, more and more air gets trapped everytime they breath in and so there is less space on that side so everythin is pushed away from it
how is tension oneumothorax managed?
insert a large bore cannula in the 2nd ICS MCL just above the 3rd rib to avoid puncturing the neurovascular bundle
what colour are large bore cannulas?
orange or grey
what is ARDS?
non cardiogenic pulmonary oedema
what criteria is used to identify ARDS and what does it contain?
berlin criteria: no alternative cause for the pulmonary oedema rapid onset <1 week SOB bilateral signs on CXR
what causes ARDS?
acute hypoxemic lung injury
what are some examples of things that cause ARDS?
sepsis acute pancreatitis covid 19 pneumonia ventilation severe burns tranfusion reactions drug OD
why do people die due to tension pneumothorax? explain the process
due to severe hypotension
the mediastinal shift reduced outflow of blood from the heart and this causes hypotension and will eventually lead to death
what is aetiology of ARDS?
a huge inflammatory response causes bursting and collapse of alveoli
what is seen on CXR in ARDS?
diffuse bilateral opacities
how is ARDS managed?
refer them to ICU
may be intubated, lie the patient prone (on tummy)
