Respiratory Emergencies Flashcards
PE immediate investigation
Wells Sore
Which scores on Well’s give 3?
Clinical DVT
PE is number 1 diagnosis or equally likely
Which scores on Well’s give 1.5?
HR>100
Immobilisation 3 days or surgery in last 4 weeks
Previous PE/DVT
Which scores on Well’s give 1?
Haemoptysis
Malignancy with treatment within 6 months or palliative
Well’s score diagnosis how
> 4 = PE likely
What to do if Wells score says PE likely?
- admit
- CTPA
- LMWH/fondaparinux
What to do if Well’s score says PE unlikely?
- D dimer
- if positive = admit, CTP, LMWH
- if negative = consider alternatve diagnosis
CI to porcine based treatments
offer fondaparinux instead
Treatment for PE
- LMWH and warfarin
- fondaparinux
How long LMWH for?
- at least 5 days
- or until INR stable
Cancer PE what drugs
LMWH alone
Bleeding risk/need surgery in PE what drugs
UH
Severe renal failure in PE what drugs
UH (measure APTT)
LMWH (measure anti Xa)
Pregnancy PE what drugs
LMWH (>3/12 at least 6 weeks post natal)
Tietze syndrome
- very rare
- inflammatory condition
- costochondral junction
- diagnosis of exclusion
Pericarditis
- inflammation of pericardium
- sudden onset
- chest, back, shoulders
- better sitting up
- worse on inspiration and lying back
Pericarditis on ECG
- PR segment depression
- widespread concave ST elevation
- reciprocal ST depression and PR elevation in aVR and V1
- absence of reciprocal ST depression elsewhere
Spontaneous pneumothorax management
- haemodynamically unstable proceed to chest drain
Secondary pneumothorax define
age >50
smoking history
underlying lung disease on exam or CXR
When to chest drain secondary pneumothorax?
- if >2cm or breathes
When to aspirate secondary pneumothorax?
- if 1-2cm
- if not successful and not now <1cm = chest drain
What to do if 2ndry pneumothorax <1-2cm?
- admit
- high flow oxygen (uncles oxygen sensitive)
- observe for 24 hours
When to aspirate primary pneumothorax?
- size >2cm and or breathless
- if not success and still >2cm = chest drain
When to discharge primary pneumothorax?
- size<2cm
- not breathless
- consider discharge in OPD in 2-4weeks
What does 1 marijuana joint equate to in cigarettes?
2.5-5
How to aspirate pneumothorax?
- aspirate with 16-18G cannula
- aspirate <2.5L
Persistent air leak in pnuemothoax
- after chest drain not much improvement
- may suggest large bore but no evidence for this
- CT scan
- never clamp bubbling chest drain!!
- consider suction
Suction pneumothorax
- low pressure negative suction
- helps appose pleura and allow to heal
Video-assisted thoracoscopy
- for persistent air leak post chest drain
- stapling of pleura in area of leak
- pleurodesis
RF of pneumothorax
- tall thin men
- cigarette smoking x22
- cannabis
- males>
- age 15-34 then over 55s
2ry pneumothorax causes
COPD>> Asthma CT disorder (marfan's) interstitial lung disease (fibrosis) lung infection (TB) CF
Symptoms of pneumothorax
Sudden onset
Pleuritic chest pain
SOB
Resp differentials of pneumothorax
Pneumonia
PE
Acute exacerbation
Cardiology differentials of pneumothorax
ACS/MI
Pericarditis
Aortic dissection/aneurysm rupture
Cardiac tamponade
Signs of pneumothorax
- reduced expansion on that side
- hyper-resonant percussion
- quiet breath sounds
- tachycardia
Subcutaneous emphysema
Air underneath skin and can feel it bubbling
If in neck region can cause breathing problems
Ix of pneumothorax
CXR
ECG (tachy)
CT Chest (may just be bubble in lung)
FBC
Pneumothorax CXR
Lung edge see collapsed
No peripheral lung markings around edge
Size (>2cm large, hilar point to edge of lung)
Pneumothorax Conservative management
- high flow oxygen
- observe and monitor
Pneumothorax Medical management
- pleural aspiration
- chest drain
- suction
- medical pleurodesis
Surgical Pneumothorax management
- open thoracotomy
- VATS
Safe triangle
- lateral edge of pectoralis major
- lateral edge of lat dorsi
- 5th ICS
- base of axillae
(above the rib to avoid neurovasc bundle)
tension pneumothorax presentation
- severe breathlessness
- tachycardia
- pulsus paradoxus
- distended jugular veins
- tracheal deviation
- ipsilateral reduced/absent breath sounds
Tension pneumothorax tx
- large bore cannula (14G)
- 2nd ICS
- mid clavicular line
- hiss of air as release tension
- don’t wait for CXR!
- needle decompression
Advice post pneumothorax
- never dive again
- no airplane travel for 2-6 weeks
- pregnancy increases risk so monitor
- stop smoking
Major RF for VTE
DVT Previous VTE Immobility Surgery within 2 months (orthopaedic>>) - malignancy (brain cancer) - pregnancy (6w post partum) - lower limb trauma/fracture (THROMBOSIS pneumonic)
Symptoms of PE
- none
- SOB
- chest pain (pleuritic)
- haemoptysis
Signs of PE
- tachypnoea
- low grade fever
- sinus tachycardia
- hypoxia
- localised pleural rub
- DVT
Massive PE Presentation
- may not get pleuritic chest pain, may be central
- hypoxia
- hypotension, collapse, cardiac arrest, sudden death
- acute right heart strain
- right heart failure
PE Dx
- history and exam
- pre test score
- CXR (normal?)
- ECG (sinus, tachy)
- bloods (D dimer)
- arterial blood gases
- CT pulmonary angiography (gold standard)
- V/Q scan(only if CXR normal)
- Echo if cannot do CTPA
Iconic signs on Dx for PE
- Hampton’s Hump
Westermark’s Sign
S1Q3T3
Imaging PE when?
- massive within 1 hour
- non massive within 24 hours
(CTPA gold standard)
Pregnancy PE
- Wells and D dimer unhelpful
- LMWH
- CXR with lead protection for fetus and breast sensitive
- ECG
- leg US and treat clot there
- VQ lower breast cancer risk but childhood cancer risk
- CTPA more definitive
- no warfarin
- DOACs can consider
- continue tx at least 6 months post natal
PE management
- anticoagulation
- thrombolysis (massive, unstable)
- rare surgery
What is the target INR?
2-3
UFH
- bleeding risk
- rapid reversal possible
- regular blood tests need
- rapid anticoagulation
