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Emergency Medicine Assistantship > Respiratory Emergencies > Flashcards

Respiratory Emergencies Flashcards

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1
Q

A patient comes to A+E with a productive cough and severe shortness of breath. What other symptoms and signs might indicate pneumonia?

A 
Fever
Chest pain
Coryzal symptoms
Headaches
Muscle pain
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2
Q

What clinical features predict adverse prognosis in acute pneumonia?

A
  • Confusion
  • Urea >7
  • RR >30
  • Hypotension
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3
Q

How should an acute pneumonia be approached initially?

A

ABCDE of course!

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4
Q

What signs might a patient with acute pneumonia have that would indicate possible ITU admission?

A
  • Respiratory failure
  • Acidosis
  • Hypoperfusion
  • Progressive exhaustion
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5
Q

What is the pathophysiology of pneumonia?

A

Acute infection causing inflammation of alveoli and terminal bronchioles with intense infiltraion of neutrophils.

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6
Q

What are the common organisms for community acquired pneumonia?

A
  • Strep. pneumoniae
  • Staph. aureus
  • Mycoplasma pneumoniae
  • H. influenzae
  • Chlamydophila pneumoniae
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7
Q

What signs of pneumonia are often found on examination?

A
  • Tachypnoea
  • Bronchial breathing
  • Crepitations
  • Pleural rub
  • Dullness to percussion
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8
Q

What is the scoring system admission criteria for pneumonia?

A

CURB-65 score - consider admission if score 2+ points:

  • Confusion
  • Urea over 7mmol/L
  • Resp rate over 30
  • BP under 90 mmHg systolic or 60mmHg diastolic
  • Age 65+
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9
Q

What are the essential management points for pneumonia?

A

-Abx
-Oxygen
-Fluids
-Analgesia
Nebulised saline for expectoration

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10
Q

What are the atypical organisms that cause pneumonia most commonly?

A
  • Mycoplasma pneumoniae
  • C. pneumonia
  • Legionella pneumophila
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11
Q

How common are atypical organisms in causing pneumonia?

A

May account for around 30% of all CAP.

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12
Q

What is the difference between severe asthma and status asthmaticus?

A

Status asthmaticus does not respond well to immediate care and is a medical emergency.

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13
Q

True or false - around 70% of deaths from asthma are thought to be preventable?

A

False - around 90% are thought to be preventable.

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14
Q

How can we tell someone has severe asthma from the history?

A
  • Previous near fatal episodes
  • Previous hospital admissions
  • Use of 3+ types of asthma medication
  • Heavy use of beta 2 agonists
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15
Q

Is a pt who is asthmatic and sensitive to NSAIDs more or less likely to have severe asthma?

A

More likely.

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16
Q

Is a history of good or poor asthma control more likely in a pt who presents with a severe asthma attack?

A

Poor control

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17
Q

What are the signs and symptoms of a moderate asthma attack?

A

PEF more than 50-75% of best or predicted

No features of severe asthma but with worsening symptoms

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18
Q

What are the signs and symptoms of a severe asthma attack?

A
  • PEF 33-50% of best or expected
  • RR 25+
  • HR 110+
  • Unable to complete sentences in one breath
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19
Q

What are the signs and symptoms of a life threatening asthma attack?

A
  • PEF 33% or worse of best or expected
  • Sats under 92%
  • PaO2 <8 kPa
  • Normal PaCO2
  • Exhaustion/altered LoC
  • Hypotensive
  • Arrthymias
  • Cyanosis
  • Silent chest
  • Poor respiratory effort
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20
Q

What are the general measures for managing an acute asthma attack in an adult?

A

ABCDE, with:

  • High flow oxygen
  • B2 agonist nebulisers
  • Steroids
  • Ipatropium bromide nebuliser
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21
Q

What are the target saturations for a pt with an acute asthma attack?

A

94-98%

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22
Q

When can IV Beta 2 agonists be used for acute asthma?

A

In those pts where inhaled therapy is not reliable

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23
Q

When can PEF values be used to determine the severity of an asthma attack?

A

Only if recent best PEFs are available for the last 2 years.

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24
Q

What PaCO2 is most concerning in acute asthma?

A

Raised as it indicates that the respiratory effort is exhausted

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25
Q

What are the 2 main factors that contribute to poor outcomes in asthma attacks?

A
  • Failure to recognise severity properly

- Under-use of corticosteroids

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26
Q

What dose of inhaled salbutamol is given by nebuliser for any acute asthma?

A

5mg

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27
Q

What dose of inhaled prednisolone is given for moderate asthma?

A

40-50mg PO

28
Q

What dose of steroids is given for acute severe or life threatening asthma?

A

Prednisolone 40-50mg PO

Hydrocortisone 100mg IV

29
Q

What dose of ipatropium bromide is given for life-threatening asthma?

A

0.5 mg

30
Q

What complications can occur secondary to status asthmaticus?

A
  • Aspiration pneumonia
  • Pneumomediastinum/thorax
  • Rhabdomyolysis
  • Respiratory or cardiac arrest
  • Hypoxic-ischaemic brain injury
31
Q

When might a traumatic pneumothorax occur?

A

Following penetrating chest trauma e.g. stab wound, gunshot injury, or fractured rib.

32
Q

When might an iatrogenic pneumothorax occur?

A
  • Mechanical ventilation
  • Central line placement
  • Lung biopsy
  • Percutaneous liver biopsy
33
Q

What immediate management should be performed for a tension pneumothorax?

A

Oxygen and emergency needle decompression.

34
Q

Describe how decompression of a tension pneumothorax should be performed?

A

With a large-bore needle into the pleural space, MCL 2nd ICS.

35
Q

What are the typical symptoms of a pneumothorax?

A

-Sudden onset chest pain and shortness of breath

36
Q

What imaging is recommended for confirmation of a pneumothorax?

A

Erect chest xray - but not for a tension pneumothorax as this should be confirmed by air decompression in initial management.

37
Q

Describe what the chest examination is like for a pneumothorax?

A
  • Reduced air entry on affected side
  • Trachea deviated away from side of collapse
  • Hyper-resonance over pneumothorax
  • Breath sounds reduced
38
Q

How should a tension pneumothorax be managed following initial decompression?

A

Insertion of chest drain depending on severity

39
Q

Where are chest drains inserted?

A

4th-5th intercostal space, mid axillary line, over the superior rib margin.

40
Q

Why should a chest drain be inserted just above the rib rather than just below?

A

To avoid the neurovascular bundles which run along the inferior border of each rib.

41
Q

What are the complications of chest drain insertion?

A
  • Pain
  • Intrapleural infection
  • Wound infection
  • Drain dislodgement
  • Drain blockage
42
Q

What is a pulmonary embolism?

A

Thrombo-embolic obstruction of the pulmonary arterial tree causing repsiratory distress and dyspnoea

43
Q

What are the causes of a PE?

A
  • Thrombosis from distant vein
  • Fat embolus
  • Amniotic fluid
  • Air
44
Q

When might a fat embolus causing a PE occur?

A

Following a long bone fracture or orthopaedic surgery

45
Q

What is the most common cause of PE?

A

Embolus from DVT.

46
Q

What are the big risk factors for a PE?

A

Increased blood coagulability
Reduced mobility
Blood vessel abnormalities

47
Q

Which groupd of people are at risk of a PE due to decreased mobility?

A
  • Surgical patients
  • Limb injuries/problems
  • Elderly
  • Spinal cord injuries
  • Long distance sedentary travel
48
Q

What are the major risk factors for a PE?

A
  • Surgery
  • Obstetric patients
  • Lower limb problems
  • Malignancy
  • Reduced mobility
  • Previous VTE
  • Major trauma
49
Q

A patient presents with sudden onset SoB and chest pain. What other symtpoms might indicate a PE?

A
  • Pleuritic or retrosternal chest pain
  • Cough
  • Haemoptysis
  • Signs of DVT
50
Q

What is the most common finding on an ECG for a PE?

A

Sinus tachycardia

51
Q

What are the textbook findings for a PE on ECG?

A
  • Tachycardia
  • S1Q3T3 pattern
  • ST depression or signs of ischaemia if large
52
Q

What signs might a patient with a PE have?

A
  • Tachycardia
  • Tachypnoea
  • Hypoxia
  • Pyrexia
  • Elevated JVP
  • Shock
  • Pleural rub
  • Gallop rhythm
53
Q

If a PE is suspected, do we wait for a diagnosis to treat?

A

No, give treatment dose LMWH then confirm diagnosis later.

54
Q

What score can we use to assess risk for PE?

A

Well’s score

55
Q

If a patient scores likely for a PE on Well’s score, what should be done?

A

Start LMWH and send for CTPA

56
Q

If a patient has a ?PE but also has renal impairment, what can we do instead of CTPA?

A

V/Q SPECT scan

57
Q

If a patient has an otherwise unprovoked PE, what blood tests should we do?

A

Antiphospholipid antibodies

58
Q

What are the points of the Well’s score?

A
  • DVT suspected? 3
  • Alt diagnosis less liekly? 3
  • Tachycardic? 1.5
  • Reduced mobility? 1.5
  • Hx of DVT/PE? 1.5
  • Haemoptysis? 1
  • Malignancy? 1
59
Q

At what score on Well’s score is a PE likely?

A

More than 4 points

60
Q

What is the S1Q3T3 pattern on an ECG classically found with a PE?

A
  • Deep S waves in Lead I
  • Q waves in Lead III
  • Inverted T waves in Lead III
61
Q

What blood test is done for a PE investigation, and how useful is it?

A

D-dimer - if it is negative, it is very useful as it is very sensitive, but if it is positive it isn’t very helpful as it is not very specific.

62
Q

A patient presents with dyspnoea and a swollen right leg. What specific investigation can we do?

A

Leg ultrasound

CTPA or V/Q scan

63
Q

What needs to be checked before LMWH is started in a patient with a PE?

A

Renal function
Allergies
Bleeding risk assessment

64
Q

How do we assess bleeding risk before starting LMWH?

A

HAS-BLED score

65
Q

What are the elements of has-bled score?

A
  • HTN >160? 1
  • Renal disease? 1
  • Liver disease? 1
  • Stroke Hx? 1
  • Major bleeding or bleeding risk? 1
  • Labile INR? 1
  • Age over 65? 1
  • Drugs predisposing to bleeding? 1
  • Alcohol >8 units/wk? 1
66
Q

When should thrombolysis be considered for a PE?

A

If they are haemodynamically unstable or if anticoagulation cannot be offered.

Emergency Medicine Assistantship (12 decks)

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