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FRCEM SBA > Respiratory > Flashcards

Respiratory Flashcards

1
Q

When does the BTS state that patients should have had NIV started if appropriate? (2)

A
  1. 60 mins of ABG
  2. 120 mins from arrival to hospital
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2
Q

When and how does BTS recommend patients on NIV are reviewed? (3)

A
  1. ABG within 2 hours and if worse the specialist review within 30mins
  2. 4 hour review by ‘appropriate health professional’
  3. Consultant review within 14 hours
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3
Q

What type of ventilator target strategy does BTS recommend for T2RF?

A

Pressure targeted (pressure support or pressure control)

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4
Q

What does BTS say about sedation and NIV? (3)

A
  1. Only if not suitable for I+V
  2. Close observation
  3. 2.5-5.0mg morphine +/- benzo
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5
Q

What ventilator settings does BTS suggest for T2RF?

A
  1. I:E 3:1 or higher
  2. RR 10-15
    3 PEEP shouldn’t normally exceed >12cm H20
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6
Q

What does BTS say about T2RF in asthma and NIV?

A

Do not use

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7
Q

What does BTS recommend re: NIV in those with restrictive lung disease (MND/chest wall disease)

A

Early NIV, they can deteriorate rapidly. Do not wait for acidosis

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8
Q

What does BTS say with regards to OHS and NIV? (2)

A
  1. May need pressures IPAP >30 and EPAP >8
  2. Fluid overload common - may need diuresis
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9
Q

Describe the step-wise approach to chronic asthma management in adults

A
  1. Salbutamol PRN
  2. Low dose inhaled corticosteroid BD (ICS)
  3. Long acting B-agonist (LABA) - consider combing with ICS to increase compliance)
  4. Consider increasing ICS to medium dose or adding leukotriene receptor antagonist (LTRA)
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10
Q

In adults what defines a moderate exacerbation in adults? (2)

A
  1. No features of severe
  2. PEF 50-75%
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11
Q

What features define severe asthma exacerbation in adults? (4)

A
  1. PEF 33-50%
  2. RR 25 or more
  3. HR 110 or more
    4, Unable to complete sentences
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12
Q

What features define life threatening asthma in adults? (10)

A
  1. PEF <33%
  2. <92% SATs
  3. Pa02 <8 KPA
  4. ‘normal’ C02
  5. Reduced GCS
  6. Exhaustion
  7. arrhythmia
  8. Hypotension
  9. Silent chest
  10. Cyanosis
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13
Q

What features define ‘near fatal’ asthma exacerbation in adults? (2)

A
  1. Hypercapnea
  2. I+V
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14
Q

Which asthmatics should be admitted? (3)

A
  1. Near fatal
  2. Life threatening
  3. Severe persisting post tx
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15
Q

Who does BTS suggest maybe suitable for discharge with regards to asthma exacerbation in adults?

A

If PEF >75% after 1 hour of tx

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16
Q

What does BTS say about steroids and pregnancy in asthma exacerbation?

A

Do not withhold steroids from women who need them

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17
Q

Which adult asthma exacerbations should see their GP and in what time frame?

A

All and within 24 hours

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18
Q

In terms of asthma exacerbations in adults who should respiratory follow up and for how long? (2)

A
  1. Severe asthma admitted - for one year
  2. Near fatal - lifetime
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19
Q

In asthma in children what characterises acute severe exacerbations? (5)

A
  1. SATS <92%
  2. PEF 33-50%
  3. Can’t compete sentences or feed
  4. HR >140 1-5years
    HR >125 > 5 years
  5. RR >40 1-5 years
    RR >30 >5 years
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20
Q

What characterises life threatening asthma in children? (7)

A

SATS <92% + one of:

  1. Exhaustion
  2. Confusion
  3. Hypotension
  4. Cyanosis
  5. Decreased resp effort
  6. Silent chest
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21
Q

What does BTS recommend re: bronchodilators in acute paeds asthma exacerbation? (3)

A
  1. Salbutamol via pMDI and spacer
  2. If poor response or life threatening then add 250mcg ipratropium (<5years) and nebulise
  3. Consider adding 150mg MgSO4 to each neb in first hour if decreased SATs
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22
Q

What are the recommended paeds doses for steroids by BTS? (3)

A

Give early and repeat if vomit
1. < 2 years = 10mg
2. 2-5yrs = 20mg
3. >5yrs = 30-40mg

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23
Q

What does BTS recommend re: IV management of asthma? (3)

A
  1. IV magnesium sulphate 40mg/kg first line
  2. Early single bolus IV salbutamol if severe and poor response - 15mcg/kg
  3. Aminophylline if severe and max dose steroids and bronchodilators
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24
Q

What does BTS suggest as discharge criteria for paeds asthma? (2)

A
  1. 3-4 hourly inhalers
  2. PEF >75%
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25
Q

What follow up should children with asthma attending hospital have? (3)

A
  1. Follow up GP 48 hours
  2. Paeds asthma clinic 1 month
  3. Life threatening should have paeds resp follow up
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26
Q

What are some of the common symptoms of CO poisoning and which is the most common? (5)

A
  1. Headache (most common)
  2. Nausea/vomiting
  3. Drowsiness
  4. SOB
  5. Chest pain
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27
Q

What COHB levels are:
1. Normal (2)
2. Threshold for tolerance
3. Severe poisoning

A
  1. 3% non-smokers and <10% in smokers
  2. 15%
  3. 30%

NB late presentations may have normal levels

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28
Q

What is the pathophysiology of CO poisoning?

A

CO binds to Hb decreasing its O2 carrying capacity and this leads to tissue hypoxia

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29
Q

What is the treatment for CO poisoning? (3)

A
  1. 15L 02 - decreases half life from 320 mins to 80mins
  2. Low BP - resuscitate
  3. If acidotic bicarbonate
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30
Q

With regards to discharging patients with CO poisoning what must we ensure? (2)

A
  1. PHE aware
  2. House now safe
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31
Q

What are the 3 risk stratification scores that can be used to decide if PEs can be managed as an outpatient and what scores do you need to have? (3+3)

A
  1. PESI = class I/II
  2. sPESI = 0
  3. Meets Hestia criteria
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32
Q

Aside from the risk stratification score, what other exclusion criteria does BTS have for outpatient management of PEs? (7)

A
  1. Unstable
  2. Active bleeding
  3. Full dose anticoagulation
  4. Severe pain
  5. Social reasons
  6. CKD 4/5
  7. HIT in last year
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33
Q

What does BTS recommend for tx or suspected and confirmed PE? (2)

A
  1. Rivaroxaban
  2. Apixiban
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34
Q

With regards to pregnancy and outpatient PE management what do we need to change in our approach? (2)

A
  1. PESI/sPESI not validated
  2. Can’t used DOACS/VKAs - LMWH
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35
Q

If patients have malignancy what should we do differently when deciding outpatient management? (2)

A
  1. Hestia criteria can be used
  2. Needs consultant review due to increased 30 day mortality
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36
Q

With regards to PE and whether we can manage as an outpatient, what difference does the fact a patient is an IV drug user make?

A

They should be admitted

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37
Q

With regards to PE and whether we can manage as an outpatient, what difference does the fact a patient is an IV drug user make?

A

They should be admitted

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38
Q

What ECG changes are common with PE? (4)

A
  1. Sinus tachy
  2. TWI V1-4
  3. S1Q3T3
  4. RBBB
39
Q

What two pre-test probability tests for PE do ESC recommend?

A
  1. Wells
  2. Geneva
40
Q

What makes up the Wells PE score? (7)

A
  1. Clinical signs/symptoms of PE or DVT (3)
  2. PE #1 diagnosis or equally likely (3)
  3. HR >100bpm (1.5)
  4. Immobilisation > 3 days or surgery in last month (1.5)
  5. Previous objective VTE (1.5)
  6. Haemoptyis (1)
  7. Malignancy (1)
41
Q

What are the pros and cons of CTPA in PE (2+1)

A

Sensitive
Picks up alternative diagnosis

High radiation dose

42
Q

What are the pros and cons of V/Q scans? (2 pros, 1 con)

A
  1. Less radiation
  2. Used if c/i to contrast
  3. More non-diagnostic scans
43
Q

What should be done before a VQ scan?

44
Q

What does a lack of RV dilatation of echo mean in high risk suspected PEs?

A

Almost excludes given haemodynamic compromise

45
Q

What is the difference for radiation CTPA vs VQ scan for pregnancy?

A

VQ scan less radiation to maternal breast tissue but no difference in radiation dose to child

46
Q

How many PE patients would have positive CUS?

47
Q

In suspected PE what is the sensitivity of a positive CUS?

48
Q

If CT/echo shows RV dilatation but everything else supports outpatient management of PE what 2 investigations can risk stratify to allow safe discharge?

A
  1. Trop
  2. BNP

If both negative then home with outpatient managemtn

49
Q

What are the features of high risk PE? (4)

A
  1. Haemodynamic compromise - SBP <90mmHg/vasopressors/arrest
  2. PESI III/IV or sPESI 1 or more
  3. RV dysfunction
  4. Increased troponin
50
Q

What makes a PE intermediate-high risk? (4)

A
  1. PESI III/IV, sPESI 1 or more
  2. RV dysfunction
  3. Raised troponin
  4. Stable
51
Q

What makes a PE intermediate low risk (3)

A
  1. PESI III/IV
  2. One or none of RV dysfunction or raised troponin
  3. Stable
52
Q

What makes a PE low risk? (4)

A
  1. Stable
  2. PESI
53
Q

How do you mange RV failure in PE? (4)

A
  1. Cautious volume loading
  2. Noradrenaline
  3. Dobutamine
  4. ECMO
54
Q

What is first line management of high risk PE? (2)

A
  1. Weight adjusted bolus UFH without delay
  2. Thromboylsis
55
Q

What is second line treatment for high risk PE (3)

A
  1. Surgical pulmonary embolectomy
  2. Percutaneous catheter directed treatment
  3. ECMO
56
Q

How do we treat intermediate risk PEs? (3)

A
  1. Treat whilst diagnosis confirmed
  2. Parenteral first line = LMWH or fondaparinox
  3. NOACs> VKA
57
Q

When are NOACs c/i? (3)

A
  1. Poor renal function
  2. Pregnancy and breast feeding
  3. Anti-phospholipid syndrome
58
Q

When should we consider IVC filters re: PE (2)

A
  1. Absolute c/i to anticoagulation
  2. Reoccurance on anticoagulation
59
Q

What are the absolute contraindications to thrombolysis? (6)

A
  1. Hx of haemorrhagic stroke
  2. Ischaemic stroke in last 6 months
  3. Brain/spinal cancer
  4. Major trauma/head injury/surgery in last 3 months
  5. Bleeding
  6. Known increased bleeding risk
60
Q

What are the relative contraindications to thrombolysis? (8)

A
  1. TIA in last 6 months
  2. Oral anticoagulation
  3. Pregnant or 1 week post partum
  4. Traumatic resusitation
  5. Refractory HTN (>180mmHg)
  6. Advancesd liver disease
  7. Infective endocarditis
  8. Peptic ulcer
61
Q

What is the minimum time for treatment of PE?

62
Q

What conditions will allow anticoagulation to be stopped after 3 months following a PE? (3)

A

A single, identifiable and reversible provoking factor

63
Q

What should prompt lifelong anticoagulation following a PE? (2)

A

Recurrent VTE
Anti-phospholipid syndrome

64
Q

What does ESC recommend for anticoagulation following PE for cancer? (3)

A
  1. LMWH first 6 months
  2. Then switch NOAC unless gastric ca
  3. Usually indefinite
65
Q

What anticoagulation is used in pregnancy and why?

A

LWMH because it does not cross the placenta

66
Q

How long should women be on anticoagulation for pregnancy provoked PE and how do we calculate the dose?

A
  1. 6 weeks post partum
  2. Early pregnancy weight
67
Q

What does ESC suggest as an investigations strategy for ? PE in pregnant women?

A
  1. CXR and CUS
  2. If DVT tx as PE
  3. If not DVT and normal CXR VQ scan or CTPA, if abnormal CTPA
68
Q

What is the NICE recommendation for Wells score cut off for PE?

69
Q

What do NICE recommend doing if Wells high but US negative? (2)

A

Add d-dimer
If positive stop anticoagulation but rescan in 1 week

70
Q

What does NICE recommend as a cut off for Wells score in PE?

71
Q

What medications does NICE recommend for anticoagulation in PE/DVT? (5)

A
  1. Rivoroxaban
  2. Apixiban
  3. LMWH for 5 days then edoxaban or (4) dagibatran if creat clearance >30
  4. LMWH until INR >2.0 followed by VKA
72
Q

What factors mean that the BTS PTX algorithm can’t be used? (3)

A
  1. Effusion
  2. Bilateral PTX
  3. Tension PTX
73
Q

What factors make a PTX secondary as opposed to primary? (2)

A
  1. > 50years and significant smoking hx
  2. Any evidence of underlying lung disease o/e or CXR
74
Q

In primary PTX what should be done if the PTX <2cm from hilum and no SOB?

A

Discharge with OPD in 2-4 weeks

75
Q

In primary PTX what should be done if >2cm and/or SOB? (2)

A

16-18 G cannula and aspiration
If following this <2cm and no longer SOB home with OPD 2-4weeks
If not chest drain and admit

76
Q

If secondary PTX is >2cm what should be done?

A

8-14 Fr chest drain

77
Q

If secondary PTX is 1-2cm what should be attempted and what are the next steps following this?

A

16-18G cannula and aspirate <2.5L
If <1cm then admit and observe 24 hours
If >1cm then 8-14Fr chest drain and admit

78
Q

If a secondary PTX is <1cm what should be done?

A

Admit 24 hours observation

79
Q

Describe the CXR scoring system for pneumonia 1-5

A
  1. Normal CXR
  2. Patchy atelectasis / bronchial wall thickening
  3. Focal alveolar consolidation but limited to one segment/lobe
  4. Multifocal consildation
  5. Diffuse alveolar consolidation
80
Q

How do we define ARDS? (3)

A
  1. Onset < 1 week
  2. Bilateral patchy infiltrates on CXR
  3. Pa02:Fi02 ratio <300 mmHg
81
Q

What are the severities of ARDS? (3)

A
  1. Mild = P/F ratio 200-300mmHg
  2. Moderate P/F ratio 100-200mmHg
  3. P/F ration <100mmHg
82
Q

What is the Pa02:Fi02 or P/F ratio?

A

Pa02 in mmHg divided by Fi02 as a fraction

e.g pa02 = 90mmHg with Fi02 40%

= 90 / 0.40
= 225

83
Q

What does CURB 65 score include?

A

Confusion
Urea > 7
Resp rate >30
B <90/60
65

84
Q

What makes a high risk CURB score

85
Q

What are the absolute contraindications to NIV? (3)

A
  1. Severe facial deformity
  2. Fixed upper airway obstruction
  3. Facial burns
86
Q

What are the relative contraindications for NIV (3)

A
  1. PH <7.15 (or 7.25 and another adverse feature)
  2. GCS <8
  3. Confusion/agitation/cognitive impairment
87
Q

What does BTS recommend commencing NIV at? (3)

A
  1. EPAP 3 (higher if OSA)
  2. IPAP 15 (unless PH <7.25 then 20)
  3. Uptitrate over 30 mins to to IPAP 20-30
88
Q

What pressures on NIV should trigger a specialist review? (2)

A
  1. EPAP >8
  2. IPAP > 30
89
Q

What makes up the PERC score? (8)

A
  1. Age <50 years
  2. Pulse <100bpm
  3. SATS 95% or more
  4. No haemoptysis
  5. No oestrogen use
  6. No surgery/trauma < 4 weeks
  7. No prior VTE
  8. No unilateral leg swelling
90
Q

What are the absolute contraindications for NIV? (3)

A
  1. Severe facial deformity
  2. Facial burns
  3. Fixed upper airway obstruction
91
Q

What are the relative contraindications to NIV? (4)

A
  1. PH <7.15 ( or <7.25 an additional adverse feature)
  2. GCS <8
  3. Confusion/agitation
  4. Cognitive impairment
92
Q

Which veins do upper limbs DVTs usually affect? (2)

A

Axillary and subclavian

93
Q

What makes up the Wells DVT score? (9 - 5 are examination findings)

A
  1. Swelling entire leg
  2. Calf swollen >3cm compared to asymptomatic leg
  3. Pitting oedema confined to asymptomatic leg
  4. Collateral superficial veins
  5. Localised tenderness over distribution of deep venous system
  6. Active cancer
  7. Recent immobilisation of lower extremities
  8. Bedridden > 3 days or major surgery within last 2 weeks
  9. Previously documented DVT

Alternative diagnosis more likely = -2

94
Q

What is the most common bacterial organism involved in sickle chest crisis?

A

Chlamydia pneumoniae

FRCEM SBA (12 decks)

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