Resp emergencies Flashcards
What is a pneumothorax
Presence of air in the pleural cavity (between the parietal and visceral pleuraa)
What are causes of pneumothorax
- Spontaneous
- Chronic lung disease (COPD, asthma, CF, lung fibrosis, sarcoidosis)
- Infection (TB, pneumonia, lung abscess)
- Trauma (inc iatrogenic)
- Carcinoma
- Connective tissue disease (marfans, ED)
What are the two types of pneumothorax
Primary (unknown cause)
Secondary (known cause - common in underlying lung disease, smoker >50)
What are symptoms and signs of pneumothorax
SOB
tachypnoea
tachycardia
cyanosis
reduced lung expansion
hyperresonance
decreased breath sounds
What are investigations for pneumothorax
Erect PA CXR
CT (gold standard)
What are signs in tension pneumothorax
severe resp distress
tracheal deviation to contralat side
what causes a tension pneumothorax
formation of a functional valve - lets air into pleural space but not out > mediastinal deviation to contralat side > risk of CARDIAC ARREST
How do you measure pneumothorax size
What is the limit size
From the lung margin to the chest wall
2cm
If primary pneumothorax: SOB and/or >2cm on CXR
Aspirate
What happens if aspiration for primary pneumothorax fails?
Insert chest drain + admit
what do you do if primary pneumothorax is small <2cm and no SOB?
reassure, analgesia if necessary, supplemental O2 therapy,
Consider discharge and outpatient review 2 weeks
what do you do for secondary pneumothorax >2cm
Chest drain
what do you for secondary pneumothorax <2cm
Aspirate. If not successful, chest drani
What is the first investigations you do for a suspected PE
CXR, ECG (sinus tachy), ABG (T1RF)
How do you use clincial probablity to assess best PE scoring system
low probability: use PERC
medium/high prob: use Well’s score
What does a 2 level Wells score tell you
> 4 points: CTPA (or VQ scan)
<=4 points: D dimer
What do you do if D dimer is low
safe to exclude PE
what do you do if D dimer is high
immediate CTPA
what do you do if CTPA is +ve
DOAC
what do you do if CTPA is negative
leg USS (for query DVT)
How do you manage haemodynamically stable PE
DOAC
- provoked: 3 months
- unprovoked: 6 months
what do you do for PE if haemodynamically stable but DOAC is contraindicated
5 days LMWH > dabigatran
OR consider IVC filter
What is ARDS
Acute and persistent lung inflammation with increased vascular permeability
What are diagnostic criteria for ARDS
Acute onset lung injury
Blateral infiltrates consistent with pulmonary oedema
Resp failure (not explained by HF)
Decreased arterial PaO2/FiO2 ratio
What is the commonest cause of ARDS
Sepsis
What are key investigations for ARDS
Sepsis 6 Bloods CXR, EECG MSU Echo
How do you manage ARDS
- Central venous access >inotropes
- Broad spectrum antibiotics, diuretics
- Oxygen
If non-shocked: sit upright
If shocked: colloid infusion
Explain PEFR in different types of asthma
life threatening: <33%
Severe: 33-50
Moderate: 50-75
When do you admit someone with moderate asthma?
never
when do you admit someone with severe asthma
If no response to treatment in A&E
What are other features of someone with severe asthma
cannot complete full sentences
High RR, high HR
What are features of life threatening asthma
CHEST Cyanosis Hypotension Exhaustion Silent chest Tachyarrithmia
When do you admit life threatening asthma
ALWAYS
What do you give for severe asthma exacerbation
High flow O
Salbutamol 5mg (back to back as req) - neb
Itratropium 0.5mg (every 4h) - neb
Pred (50mg PO) or hydrocortisone (100mg IV)
Senior support: IV mag sulphate, aminophylline, ITU+ intubation
What Ix should you get for acute exacerbate of COPD
Bloods, sputum pot ABG Blood culture ECG CXR
How do you manage COPD exacerbate
Oxygen therapy - 24% oxygen via Venturi mask (hypoxia kills quicker than hypercapnia)
Nebulisers (salbutamol, itratropium)
Prednisolone AND hydrocort
Abx (amoxicillin / co-amoxiclav, IV or PO)
What is the most common abnormality on ECG with PE, and what other abnormalities can occur?
PE: sinus tachycardia (most common).
Otherwise RBBB, S1Q3T3
What is the PE Well’s Score? summarise all points
EAT CHIP
Edema in legs and other S/S = 3 points
Alternative dx less likely than PE = 3 points
Tachycardia HR >100 = 1.5 points
Cancer = 1 point
Haemoptysis = 1 point
Immobilisation (for 3+ days) or surgery (<4 weeks ago) = 1.5 points
Prior DVT/PE = 1.5 points
where is the triangle of safety
in axilla
superior border = base of axilla
Anterior border = lat edge of pec major
Posterior border = ant edge of lat dorsi
Inferior border = 5th ICS
which causes of pneumthorax must you ALWAYS insert a chest drain for
if the cause is TRAUMA or MECHANICAL VENTILATION
ALWAYS insert a chest drain
