Respiratory

Question 1

List 8 important risk factors for PE in the ED patient

Answer 1

Most important risk factors in ED patients
•  OR > 2
•  previous VTE
•  unilateral leg swelling
• surgery in previous 4 weeks
• oestrogen therapy
•  SpO2 < 95% on air
•  non cancer related thrombophilia
• Trauma: 25% of PEs occur within 4 days of injury, 50% within one week

Question 2

In order of frequency, what are the top 7 most common symptoms in PE?

Answer 2

Dyspnoea
Pleuritic chest pain 
Apprehension
Cough
Haemoptysis
Sweats
Syncope
Non pleuritic chest pain

Question 3

What percentage of patients with symptomatic PE have no identifiable risk factors?

Answer 3

50%

Question 4

What are the Right Heart signs of PE?

Answer 4

(usually only present with large PE)

•loud pulmonary closure sound
•wide splitting of second heart sound
•right ventricular gallop
•right ventricular heave
• elevated JVP
- prominent a waves on JVP
•localised rales, rhonchi, rub

Question 5

State the 5 severity grades for PE

Answer 5

I - minimal symptoms
II - tachypnoea, tachycardia
III - hypotension, fluid responsive
IV - hypotension, needing pressor support
V - needing cardiopulmonary support

Question 6

Define massive, submassive and non massive PE. State their short term mortality.

Answer 6

Massive (High risk): Short Term mortality >15%

Haemodynamic instability with signs of shock.
Persistent hypotension (SBP <90mmHg or drop > 40mmHg from baseline SBP for longer than 15mins)

Submassive (Intermediate risk): S/T mortality 3-15%

Signs RV dysfunction or and or myocardial necrosis

• Echo - RV dilation/dysfunction. LV ‘D sign’
• CT RV dysfunction (RV:LV ratio >0.9)
• RHS on ECG
• BNP >90
• Trop I > 0.4

Non-massive (low risk): S/T Mortality <3%

• no HD instability, normal BP
• no signs RV dysfunction or myocardial necrosis

Question 7

Antimicrobial + dose for fungal infection

Answer 7

IV/PO Fluconazole 12mg/kg OD day 1 then 6mg/kg OD subsequently (systemic candidiasis, cryptococosis, prevention candida in immunocomprimised)

IV/PO fluconazole 6mg/kg OD for oral candidiasis

Amphotericin B
Severe systemic fungal infections
Adult, IV 3–5 mg/kg once daily; use the higher end of the dose range for CNS disease and fusariosis.

Child >1 month, IV, start at 1–3 mg/kg once daily; may increase up to 5 mg/kg once daily.

Empirical treatment in febrile neutropenia unresponsive to antibacterials:

Adult, child >1 month, IV 3 mg/kg once daily. Use 5 mg/kg once daily if mucormycosis suspected; seek specialist advice.

Question 8

Define massive haemoptysis.

At what volume is the mortality 20-50%?

Answer 8

Blood volume 100-1000ml/24 hours

300-600mls/24hours = 20-50% mortality

Question 9

Define exanguinating haemoptysis.

What is it’s mortality?

Answer 9

> 150mls/ 1 hour, and loss >1000mls

mortality 75%