Respiratory Emergencies Flashcards
A patient comes to A+E with a productive cough and severe shortness of breath. What other symptoms and signs might indicate pneumonia?
Fever Chest pain Coryzal symptoms Headaches Muscle pain
What clinical features predict adverse prognosis in acute pneumonia?
- Confusion
- Urea >7
- RR >30
- Hypotension
How should an acute pneumonia be approached initially?
ABCDE of course!
What signs might a patient with acute pneumonia have that would indicate possible ITU admission?
- Respiratory failure
- Acidosis
- Hypoperfusion
- Progressive exhaustion
What is the pathophysiology of pneumonia?
Acute infection causing inflammation of alveoli and terminal bronchioles with intense infiltraion of neutrophils.
What are the common organisms for community acquired pneumonia?
- Strep. pneumoniae
- Staph. aureus
- Mycoplasma pneumoniae
- H. influenzae
- Chlamydophila pneumoniae
What signs of pneumonia are often found on examination?
- Tachypnoea
- Bronchial breathing
- Crepitations
- Pleural rub
- Dullness to percussion
What is the scoring system admission criteria for pneumonia?
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+
What are the essential management points for pneumonia?
-Abx
-Oxygen
-Fluids
-Analgesia
Nebulised saline for expectoration
What are the atypical organisms that cause pneumonia most commonly?
- Mycoplasma pneumoniae
- C. pneumonia
- Legionella pneumophila
How common are atypical organisms in causing pneumonia?
May account for around 30% of all CAP.
What is the difference between severe asthma and status asthmaticus?
Status asthmaticus does not respond well to immediate care and is a medical emergency.
True or false - around 70% of deaths from asthma are thought to be preventable?
False - around 90% are thought to be preventable.
How can we tell someone has severe asthma from the history?
- Previous near fatal episodes
- Previous hospital admissions
- Use of 3+ types of asthma medication
- Heavy use of beta 2 agonists
Is a pt who is asthmatic and sensitive to NSAIDs more or less likely to have severe asthma?
More likely.
Is a history of good or poor asthma control more likely in a pt who presents with a severe asthma attack?
Poor control
What are the signs and symptoms of a moderate asthma attack?
PEF more than 50-75% of best or predicted
No features of severe asthma but with worsening symptoms
What are the signs and symptoms of a severe asthma attack?
- PEF 33-50% of best or expected
- RR 25+
- HR 110+
- Unable to complete sentences in one breath
What are the signs and symptoms of a life threatening asthma attack?
- 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
What are the general measures for managing an acute asthma attack in an adult?
ABCDE, with:
- High flow oxygen
- B2 agonist nebulisers
- Steroids
- Ipatropium bromide nebuliser
What are the target saturations for a pt with an acute asthma attack?
94-98%
When can IV Beta 2 agonists be used for acute asthma?
In those pts where inhaled therapy is not reliable
When can PEF values be used to determine the severity of an asthma attack?
Only if recent best PEFs are available for the last 2 years.
What PaCO2 is most concerning in acute asthma?
Raised as it indicates that the respiratory effort is exhausted
What are the 2 main factors that contribute to poor outcomes in asthma attacks?
- Failure to recognise severity properly
- Under-use of corticosteroids
What dose of inhaled salbutamol is given by nebuliser for any acute asthma?
5mg
What dose of inhaled prednisolone is given for moderate asthma?
40-50mg PO
What dose of steroids is given for acute severe or life threatening asthma?
Prednisolone 40-50mg PO
Hydrocortisone 100mg IV
What dose of ipatropium bromide is given for life-threatening asthma?
0.5 mg
What complications can occur secondary to status asthmaticus?
- Aspiration pneumonia
- Pneumomediastinum/thorax
- Rhabdomyolysis
- Respiratory or cardiac arrest
- Hypoxic-ischaemic brain injury
When might a traumatic pneumothorax occur?
Following penetrating chest trauma e.g. stab wound, gunshot injury, or fractured rib.
When might an iatrogenic pneumothorax occur?
- Mechanical ventilation
- Central line placement
- Lung biopsy
- Percutaneous liver biopsy
What immediate management should be performed for a tension pneumothorax?
Oxygen and emergency needle decompression.
Describe how decompression of a tension pneumothorax should be performed?
With a large-bore needle into the pleural space, MCL 2nd ICS.
What are the typical symptoms of a pneumothorax?
-Sudden onset chest pain and shortness of breath
What imaging is recommended for confirmation of a pneumothorax?
Erect chest xray - but not for a tension pneumothorax as this should be confirmed by air decompression in initial management.
Describe what the chest examination is like for a pneumothorax?
- Reduced air entry on affected side
- Trachea deviated away from side of collapse
- Hyper-resonance over pneumothorax
- Breath sounds reduced
How should a tension pneumothorax be managed following initial decompression?
Insertion of chest drain depending on severity
Where are chest drains inserted?
4th-5th intercostal space, mid axillary line, over the superior rib margin.
Why should a chest drain be inserted just above the rib rather than just below?
To avoid the neurovascular bundles which run along the inferior border of each rib.
What are the complications of chest drain insertion?
- Pain
- Intrapleural infection
- Wound infection
- Drain dislodgement
- Drain blockage
What is a pulmonary embolism?
Thrombo-embolic obstruction of the pulmonary arterial tree causing repsiratory distress and dyspnoea
What are the causes of a PE?
- Thrombosis from distant vein
- Fat embolus
- Amniotic fluid
- Air
When might a fat embolus causing a PE occur?
Following a long bone fracture or orthopaedic surgery
What is the most common cause of PE?
Embolus from DVT.
What are the big risk factors for a PE?
Increased blood coagulability
Reduced mobility
Blood vessel abnormalities
Which groupd of people are at risk of a PE due to decreased mobility?
- Surgical patients
- Limb injuries/problems
- Elderly
- Spinal cord injuries
- Long distance sedentary travel
What are the major risk factors for a PE?
- Surgery
- Obstetric patients
- Lower limb problems
- Malignancy
- Reduced mobility
- Previous VTE
- Major trauma
A patient presents with sudden onset SoB and chest pain. What other symtpoms might indicate a PE?
- Pleuritic or retrosternal chest pain
- Cough
- Haemoptysis
- Signs of DVT
What is the most common finding on an ECG for a PE?
Sinus tachycardia
What are the textbook findings for a PE on ECG?
- Tachycardia
- S1Q3T3 pattern
- ST depression or signs of ischaemia if large
What signs might a patient with a PE have?
- Tachycardia
- Tachypnoea
- Hypoxia
- Pyrexia
- Elevated JVP
- Shock
- Pleural rub
- Gallop rhythm
If a PE is suspected, do we wait for a diagnosis to treat?
No, give treatment dose LMWH then confirm diagnosis later.
What score can we use to assess risk for PE?
Well’s score
If a patient scores likely for a PE on Well’s score, what should be done?
Start LMWH and send for CTPA
If a patient has a ?PE but also has renal impairment, what can we do instead of CTPA?
V/Q SPECT scan
If a patient has an otherwise unprovoked PE, what blood tests should we do?
Antiphospholipid antibodies
What are the points of the Well’s score?
- 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
At what score on Well’s score is a PE likely?
More than 4 points
What is the S1Q3T3 pattern on an ECG classically found with a PE?
- Deep S waves in Lead I
- Q waves in Lead III
- Inverted T waves in Lead III
What blood test is done for a PE investigation, and how useful is it?
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.
A patient presents with dyspnoea and a swollen right leg. What specific investigation can we do?
Leg ultrasound
CTPA or V/Q scan
What needs to be checked before LMWH is started in a patient with a PE?
Renal function
Allergies
Bleeding risk assessment
How do we assess bleeding risk before starting LMWH?
HAS-BLED score
What are the elements of has-bled score?
- 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
When should thrombolysis be considered for a PE?
If they are haemodynamically unstable or if anticoagulation cannot be offered.
