Pneumothorax and pulmonary embolism

Question 1

Give 8 risk factors for primary spontaneous pneumothorax

Answer 1

Smoking
Tall, slim build
Male
Asian ethnicity
Marfan syndrome
Family history
Diving
Flying

Question 2

What is the definition of primary spontaneous pneumothorax?

Answer 2

Spontaneous pneumothorax occurring in the absence of underlying lung disease

Question 3

What is the definition of secondary spontaneous pneumothorax?

Answer 3

Spontaneous pneumothorax occurring in the presence of underlying lung disease

Question 4

What causes a catamenial pneumothorax?

Answer 4

Endometriosis of the pleura

Question 5

What is the gold standard investigation for pneumothorax?

Answer 5

CT

Question 6

What should be checked before insertion of a chest drain?

Answer 6

Coagulation profile

Question 7

What do ALL patients require after intervention for pneumothorax?

Answer 7

Repeat CXR

Question 8

What is the first line management of a tension pneumothorax?

Answer 8

14G cannula into 2nd intercostal space, mid-clavicular line

Question 9

How is the size of a pneumothorax determined on CXR?

Answer 9

Measure interpleural distance at level of the hilum

Question 10

What is the first line management of a breathless patient with a 1cm primary spontaneous pneumothorax?

Answer 10

Aspirate with a 16-18G cannula

Question 11

What is the first line management of a patient with a 3cm primary spontaneous pneumothorax?

Answer 11

Aspirate with a 16-18G cannula

Question 12

What is the first line management of a non-breathless patient with a 1cm primary spontaneous pneumothorax?

Answer 12

Consider discharge and review in outpatient department in 2-4 weeks

Question 13

What is the next line of management of a patient with a 3cm primary spontaneous pneumothorax whose symptoms are not improved by aspiration?

Answer 13

Admit to hospital

Insert 8-14Fr chest drain

Question 14

What is the first line management of a breathless patient with a 1cm secondary spontaneous pneumothorax?

Answer 14

Admit to hospital

Insert 8-14Fr chest drain

Question 15

What is the first line management of a non-breathless patient with a 1cm secondary spontaneous pneumothorax?

Answer 15

Aspirate with a 16-18G cannula

Question 16

What is the first line management of a non-breathless patient with a 0.5cm secondary spontaneous pneumothorax?

Answer 16

Admit to hospital
High flow oxygen
Observe for 24 hours

Question 17

What is the next line of management of a patient with a 1.5cm secondary spontaneous pneumothorax which is 1.2cm after aspiration?

Answer 17

Admit to hospital

Insert 8-14Fr chest drain

Question 18

Where should a chest drain be inserted?

Answer 18

Mid-axillary line, 5th intercostal space (triangle of safety)

Question 19

What are the borders of the safe triangle?

Answer 19

Lateral edge of pectoralis major
Lateral edge of latissimus dorsi
5th intercostal space
Top of axilla

Question 20

What intervention for recurrent pneumothorax has the lowest recurrence rate?

Answer 20

Open thoracotomy and pleurectomy

Question 21

What is the advantage of video-assisted thoracoscopic pleurectomy in management of recurrent pneumothorax?

Answer 21

Lower morbidity

Question 22

Give 6 indications for referral to surgery for pneumothorax

Answer 22

First contralateral pneumothorax
Second ipsilateral pneumothorax
Bilateral spontaneous pneumothorax
High-risk occupation
Pregnancy
Persistent air leak despite chest drain

Question 23

When can someone fly after a pneumothorax?

Answer 23

1 week post check CXR

Question 24

What advice should be given to divers after pneumothorax?

Answer 24

Avoid diving indefinitely until definitive bilateral pleurectomy AND post-op CT and lung function tests

Question 25

Give 7 NICE major risk factors for pulmonary embolism

Answer 25

``` DVT Previous VTE Active cancer Surgery within the last 2 months Significant immobility Lower limb trauma or fracture Pregnancy or up to 6 weeks postpartum ```

Question 26

Give 8 NICE non-major risk factors for pulmonary embolism

Answer 26

``` Obesity (BMI>30) Age 60+ COCP use One or more significant medical comorbidities Thrombophilia Long distance sedentary travel Varicose veins Superficial venous thrombosis ```

Question 27

Which 2 factors score 3 points each on the Wells score?

Answer 27

Signs of DVT | PE is most likely or equally likely diagnosis

Question 28

Which 4 factors score 1.5 points each on the Wells score?

Answer 28

Tachycardia Previous VTE Surgery in the last 4 weeks Immobilisation for 3+ days

Question 29

Which 2 factors score 1 point each on the Wells score?

Answer 29

Malignancy with treatment in the last 6 months or palliative treatment Haemoptysis

Question 30

What kind of chest pain is associated with a pulmonary embolism or pneumothorax?

Answer 30

Pleuritic

Question 31

Give 4 red flag symptoms for a massive pulmonary embolism

Answer 31

Syncope Elevated JVP Hypotension Right parasternal heave

Question 32

Give 4 ECG changes that might be associated with a pulmonary embolism

Answer 32

Sinus tachycardia Right axis deviation Right bundle branch block S1Q3T3 pattern

Question 33

What is the definition of an unprovoked pulmonary embolism?

Answer 33

No proven risk factor in the previous 3 months

Question 34

What is the appropriate management: possible pulmonary embolism, Wells score 4.5 or above?

Answer 34

CT pulmonary angiogram

Question 35

What is the appropriate management: possible pulmonary embolism, Wells score 4 or below?

Answer 35

D-dimer

Question 36

Give 4 things that can cause a raised D-dimer

Answer 36

Disseminated intravascular coagulation Deep vein thrombosis Pulmonary embolism Inflammation

Question 37

What is the disadvantage of a V/Q scan over a CTPA in pregnant women?

Answer 37

More radiation given to child

Question 38

What is the disadvantage of a CTPA over a V/Q scan in pregnant women?

Answer 38

More radiation to mother's breasts which are more sensitive to radiation in pregnancy

Question 39

What should be done to exclude malignancy in patients under 40 with an unprovoked pulmonary embolism?

Answer 39

CXR Urinalysis Full set of bloods

Question 40

What should be done to exclude malignancy in patients over 40 with an unprovoked pulmonary embolism?

Answer 40

CXR Urinalysis Full set of bloods CT chest/abdomen/pelvis

Question 41

Apart from excluding malignancy, what should be checked in ALL patients with an unprovoked pulmonary embolism?

Answer 41

Antiphospholipid antibodies

Question 42

When should patients with an unprovoked pulmonary embolism be tested for hereditary thrombophilia?

Answer 42

If they have a first degree relative with a VTE history

Question 43

When should the PERC criteria be considered when ruling out a PE without a d-dimer?

Answer 43

Wells score below 3

Question 44

What are the 8 PERC criteria that must NOT be present for a PE to be ruled out?

Answer 44

``` Age 50+ HR 100+bpm Previous VTE Surgery or trauma in the past 4 weeks Haemoptysis Exogenous oestrogen O2 sats <95% Unilateral leg swelling ```

Question 45

Which ECG finding is the most commonly seen finding in a pulmonary embolism?

Answer 45

Sinus tachycardia