Respiratory Emergencies Flashcards
Outline the pathophysiology of anaphylaxis
Type I IgE-mediated hypersensitivity reaction
- First time susceptible individual exposed to allergen, ++ IgE produced - attaches to mast cells
- Next time exposed, antigen binds to IgE on mast cells - leads to degranulation and hence release of mediators e.g. histamine
List some effects of systemic release of histamine in anaphylaxis
Capillary leakage - low BP - shock
Pruritis/urticaria
Angioedema - hoarseness/stridor
Bronchospasm - wheeze, chest tightness
Outline the immediate management of anaphylaxis
- A to E including securing airway and giving controlled O2 therapy. Intubate if necessary
- Remove cause, e.g. bee stings
- Lie flat and raise feet
- IM adrenaline 0.5mg (0.5ml of 1:1000). Repeat every 5 mins until BP satisfactory
- Secure IV access
- IV chlorphenamine 10mg + IV hydrocortisone 200mg
- IV fluid bolus
- Salbutamol nebs if wheeze
- If still hypotensive - ITU, IVI adrenaline
After your initial stabilisation, how would you further manage anaphylaxis?
Admit for observation (usually HDU) Monitor ECG Measure mast cell tryptase 1 - 6 hrs after reaction Continue chlorphenamine if itchy Prescribe and demonstrate epipen Refer to allergy clinic if cause unknown
What are the criteria for a mild asthma attack?
No features of severe
PEFR >75%
What are the features of a moderate asthma attack?
No features of severe
PEFR 51 - 75%
What are the features of a severe asthma attack?
Any one of the following:
- PEFR 33 - 50%
- Cannot complete sentences in 1 breath
- RR >25/min
- HR > 110bpm
What are the features of a life-threatening asthma attack?
Any one of the following:
- PEFR <33%
- Sats <92% or PaO2 <8kPa
- Cyanosis/silent chest/poor resp effort
- Exhaustion/confusion/coma
- Bradycardia/hypotension
- Normal or high pCO2
What denotes a near-fatal asthma attack?
Low pCO2
How would you manage a severe/life-threatening/near-fatal asthma attack? 5 marks
5 of the following points:
- A to E, and sit them up
- Salbutamol 2.5mg nebs back to back if needed
- Prednisolone 40mg PO stat dose
- Controlled O2 therapy
- Nebulised Ipratropium bromide 0.5mg
- Monitor ECG for hypokalaemia
- Consider IV MgSO4
- Alert ITU if severe/life-threatening/near fatal
- Consider IV salbutamol/aminophylline
- Urgent portable CXR
How would you manage a mild to moderate asthma attack?
- Salbutamol nebs as above
- Prednisolone 30mg PO stat
How would you further manage an asthma attack, following initial emergency treatment?
Nebulised Salbutamol 4 hourly
Prednisolone 40mg PO 5- 7 days
O2 to keep sats >94%
What are the criteria for safe discharge in asthma?
Patient must have:
- Been stable on discharge meds for 24 hours
- PEFR >75%
- Had inpatient asthma nurse review - inhaler technique, PEFR meter, written action plan
- Inhaled steroid and bronchodilator
- 5 further days oral Pred prescription
- GP follow-up within 48 hrs
- Resp clinic f/u within 4 wks
How would you manage a COPD exacerbation?
- A to E, inc controlled O2 therapy
- Nebulised Salbutamol and Ipratropium bromide
- Pred 30mg PO stat
- Abx if evidence of infection - normally Amoxicillin 500mg PO TDS 5 days
- Consider IV aminophylline
If, following your initial management steps, your pt with an acute COPD exacerbation is still very unwell, what should you do?
- Consider NIV if RR>30, pH 7.26 - 7.35, or PCO2 rising
- Consider I+V if pH < 2.6 and PaCO2 rising despite NIV - ring ITU
- Consider resp stimulant drug
List 4 investigations you would do for a patient with a COPD exacerbation, and justify each
- Bloods - FBC, U+E, CRP - ?infection
- ABG - ?resp failure
- CXR - ?pneumonia
- Sputum culture - ?infection
How would you initially manage pneumonia?
- A to E including controlled O2 therapy
- Sepsis 6 if features of sepsis
- Ix and CURB-65 score
- Abx based on CURB-65 score
- Analgesia for pain/fever
- Consider CPAP if still hypoxic. If hypercapnic, discuss with ITU
List 4 investigations you would do for pneumonia
- CXR
- ABG if sats <92%
- Bloods - FBC, U+E, CRP, cultures
- Urine pneumococcal/legionella antigens
- Pleural fluid aspiration if effusion
Outline the CURB-65 score and what that means clinically
Confusion Urea >7mmol/L RR>30 BP <90 systolic OR 60 diastolic Age 65+ 0 - 1 = mild - home tx 2 - moderate - admit 3+ - severe - consider ITU
Apart from CURB-65 score, what other factors should be considered in someone with pneumonia?
- Underlying resp disease
- Bilateral/multilobar pneumonia
- PaO2 <8 or sats <92%
What is the definition of massive haemoptysis?
> 240ml blood loss in 24 hours, or >100ml/day for 2+ consecutive days
How would you manage massive haemoptysis?
- A to E
- Lie pt on side of suspected lesion to prevent blood entering lung
- Oral TXA for 5 days
- Stop NAIDs/aspirin/warfarin etc
- Consider vit K
- CT aortogram +/ bronchial artery embolisation
- Ix underlying cause
List 5 signs of tension pneumothorax
- Tachycardia
- Hypotension
- Distended neck veins
- Tracheal deviation away
- Respiratory distress
How would you manage a tension pneumothorax?
- Large bore IV cannula into 2nd ICS, MCL, at superior border of inferior rib
- Chest drain
- CXR
List 4 symptoms of PE
- SOB
- Pleuritic CP
- Haemoptysis
- Syncope
List 5 signs of PE
- Low BP
- Raised HR
- Gallop rhythm
- RV heave
- Pleural rub
- DVT
- Cyanosis
List 4 Ix for PE, and what they might show/why you would do them
- Bloods - FBC, clotting, LFT - underlying cancer/clotting abnormality
- ECG - sinus tachy, or SI, QIII, TIII
- CXR - often normal, but may show wedge-shaped infarct if massive PE
- ABG if hypoxic
Which scoring system would you use for someone with a PE?
Outline its criteria
Well’s score for PE:
- Clinical signs/sx of DVT (3)
- PE is #1 DDx (3)
- HR>100 (1.5)
- Immobilisation 3+ days, or surgery in last 4 wks (1.5)
- Previous VTE (1)
- Haemoptysis (1)
- Malignancy treated within last 6 months, or palliative (1)
What do a Well’s score of 0-4 and >4 indicate?
0 - 4 - PE unlikely - consider doing a D-dimer. If -ve, almost definitely not PE. If +ve, CT-PA.
If >4, no need for D-dimer as PE likely - do CT-PA.
What criteria denote a massive PE?
- Hypotension/peri-arrest
- Confirmed signs of RV strain on CT/ECHO (but don’t do scan if peri-arrest obviously)
How would you manage a massive PE?
- A to E inc controlled O2 therapy
- Morphine + anti-emetic if in pain or distressed
- Consider immediate thrombolysis - 50mg IV alteplase
List 5 absolute contraindications to thrombolysis
- Haemorrhagic stroke
- CNS neoplasia
- Recent trauma or surgery
- GI bleed in last month
- Bleeding disorder
- Aortic dissection
List 5 relative contraindications to thrombolysis
- Warfarin
- Pregnancy
- Advanced liver disease
- IE
List 5 possible complications of thrombolysis
- Bleeding
- Hypotension
- Anaphylaxis
- Intracranial haemorrhage/stroke
- Embolisation of thrombus
How should you manage a non-massive PE?
- A to E
- Morphine if in pain
- Start heparin (usually LMWH)
- If BP >90, start Warfarin regime
- If BP <90, start fluids, ITU input and consider norad IVI
After your initial stabilisation, how would you further manage a PE?
- TED stockings for further prevention
- LMWH with warfarin until INR >2, then stop heparin
- If cause known and reversible, e.g. COCP, warfarin for 6 - 12 wks
- Otherwise refer to haem, and continue warfarin for 3 - 6 months+
