Post-op SOB Flashcards
What would you say on the phone before seeing the patient?
- high flow O2 through NRM
- 12 lead ECG
- IV access
- prepare equipment for blood, get VBG
A + B
Airway:
- Ensure the airway is patent
Breathing:
- Check oxygen saturations and respiratory rate
- Continue high flow oxygen (15L through non re-breather mask)
- Inspect, percuss and auscultate chest
- Arterial blood gas
- Chest X-Ray
C + D
Circulation
- Check blood pressure and pulse rate
- Assess peripheral circulation (warm well-perfused or cool/ clammy)
- Capillary refill time
- Jugular venous pressure, Auscultate heart sounds
- 12 lead ECG
- Gain intravenous access (bilateral wide bore cannula)
- Bloods to include FBC, U&Es, Clotting, Group and Save
Disability:
- AVPU score
- Blood glucose
- Temperature
- Pupillary response
E +
- Inspect hemiarthroplasty wound site and observe for any signs of surrounding cellulitis, underlying collection or wound dehiscence
- Palpate calves bilaterally
- At this point (if the patient is haemodynamically stable), review the patient notes, recent biochemistry/haematology results, drug chart and operation note.
- Escalate: inform your senior to make them aware as soon as possible.
What are your differential diagnoses?
post-op hemiarthroplasty, low sats
Main: PE
Other:
- fat embolism
- pneumonia
- atelectasis
- pulm oedema
- other sources of sepsis
- anxiety
- Covid
- acute pain
What investigations would you order?
Bedside:
- 12 lead ECG
- Wound swab sample for MC&S
- Urine dipstick and MC&S
- COVID-19 PCR swab
Haematological:
- Arterial blood gas (more relevant in this case rather than venous)
- FBC, U&Es, Clotting, (Blood culture if pyrexial)
Radiological:
- Chest X-Ray – to assess for consolidation, pneumothorax, large pulmonary emboli or pulmonary oedema
- CT Pulmonary angiogram – to rule out pulmonary embolus
- Ultrasound scan of hip wound (if clinically suspecting underlying collection)
What would you review in the patient’s notes?
1.Charts:
- Observation charts – review trends observations e.g. respiratory rate, pulse rate, oxygen saturation and if changes have been sudden or gradual
- Fluid balance chart (properly documented? Any fluid overload which can result in pulmonary oedema.
- Any missed medication e.g. LMWH
2.Clinical and operation notes:
- Operation note: any complications encountered during operation and in the perioperative period. Any specific post-operative recommendations noted e.g. hold off VTE prophylaxis due to ‘oozy wound’/ post-operative bleeding
- Patient medical history – , any significant past medical history e.g. Thrombotic disease, Malignancy, COPD/Asthma, Previous DVT/PE, Thrombophilias. Smoking status.
- Drug history (over the counter included- e.g. HRT),
- Post-operative reviews – acute deterioration or gradual? Any concerns identified previously?
3.Available results
- Recent blood tests or blood gases for trends
What are risk factors for developing a DVT or PE?
- Recent surgery
- Recent fractures
- Recent immobility
- Personal or family history of a clotting disorder or PE/DVT
- Obesity
- Malignancy
- Infection
- Pregnancy
- Certain medications such as the combined oral contraceptive pill or hormone replacement therapy
What scoring system can be used to assess the likelihood of a PE and to guide your investigation of choice?
Well’s
Above what score is a CTPA indicated, and in this case would a D-Dimer be of value?
Well’s score of >4 – CTPA is indicated
D-Dimer would not be of much value due to the recent surgery the patient has undergone
What would be your classical ECG finding in a patient with a PE?
Sinus tachycardia is the most common ECG finding
However, the “S1Q3T3” pattern of acute cor pulmonale is classic; this is termed the McGinn-White Sign. A large S wave in lead I, a Q wave in lead III and an inverted T wave in lead III together indicate acute right heart strain
What arterial blood gas result would you get in the case of a PE?
Respiratory alkalosis with Type 1 respiratory failure
A CT Pulmonary angiogram was carried out which noted a right- sided sub-massive pulmonary embolus. What would your definite management of this patient be?
- commence on anticoagulant according to local policy for at least 3 months (consider CI, co-morbidity, pt preference)
- reassess using A-E
- review bloods
- inform senior before prescribing Tx dose anticoag, consider d/w haem and pharmacy
apixaban/rivaroxaban is 1st line
What is fat embolism syndrome?
Fat embolism syndrome is a life-threatening complication occurring when embolic fat macroglobules enter small vessels in the lung and other organs, producing endothelial damage and resulting respiratory failure (ARDS-like picture), cerebral dysfunction and a petechial rash.
What is fat embolism syndrome caused by?
FES is most frequently following closed fractures of long bones.
Other causes include
- Orthopaedic procedure (most commonly IM nailing of long bones, knee or hip arthroplasties
- Massive soft tissue injury
- Severe burns
- Bone marrow biopsies
- Non-trauma setting e.g. liposuction, acute pancreatitis and osteomyelitis.
