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Year 3 - CR > Respiratory Emergencies > Flashcards

Respiratory Emergencies Flashcards

1
Q

What is a pneumothroax

A
  • Air in the pleural space
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2
Q

What are the causes of spontaneous pneumothorax

A
  • Primary - normal lung

- Secondary - underlying lung disease

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3
Q

Who does a spontaneous peneumothorax commonly occur in

A
  • tall, thin men
  • male: female 5:1
  • cigarettes 22x more common
  • cannabis
  • rarely familial
  • biomodal - more commonly in 15-34 and then over 55s
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4
Q

What is the pathophysiology of a pneumothorax

A

Air leak from Apical bulla in visceral pleura leading to a right spontaneous pneumothorax

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5
Q

What is the cause of secondary pneumothorax

A
  • COPD (60%)
  • Asthma
  • Connective tissue disease – Marfan’s
  • Interstitial lung disease : fibrosis
  • Lung infection = Tuberculosis
  • Cystic Fibrosis
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6
Q

What are the clinical symptoms of pneumothorax

A
  • Sudden onset/acute
  • Pleuritic chest pain
  • +/-SOB
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7
Q

What are the differential diagnosis for pneumothorax

A

Respiratory

  • pulmonary embolus
  • pneumonia
  • acute exacerbation of respiratory disease

Cardiovascular

  • acute coronary syndrome/MI
  • pericarditis
  • aortic dissection/aneurysm rupture
  • cardiac tamponade

Other

  • musculoskeletal pain
  • GORD
  • Panic attack
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8
Q

What are the clinical signs of pneumothorax

A
  • reduced expansion
  • hyper-resonant percussion
  • quiet breath sounds
  • tachycardia
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9
Q

What is a cause of subcutaneous emphysema

A
  • spontaneous pneumothorax

-

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10
Q

How do you investigate a pneumothorax

A
  • CXR
  • ECG
  • bloods
  • CT chest
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11
Q

what do you see in a chest X ray of someone with a pneumothorax

A

CXR

  • Lung edge
  • No peripheral lung markings
  • Small <2cm
  • Large ≥ 2cm (50%)
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12
Q

What is the difference between a small and large pneumothorax

A
  • Small <2cm

- Large ≥ 2cm (50%)

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13
Q

How do you manage pneumothorax

A

Conservative

  • observation
  • high flow oxygen
Medical 
- pleural aspiration 
- chest drain 
- suction 
- medical pleurodesis - can use Tetracycline/doxycycline / Talc
to stick the pleural together

Surgical - stick visceral and parietal pleura together

  • open thoractomy
  • video assisted thoracic surgery (VATS)
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14
Q

what makes up the safe triangle

A
  • lateral edge of pec major
  • base of axilla
  • 5th intercostal space (go in above a rib)
  • lateral edge of lat doors
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15
Q

describe the management of a primary pneumothorax

A
  • Primary pneumothorax and less than 2cm discharge and review in OPD in 2-4 weeks
  • if primary pneumothorax and greater than 2cm then aspirate with 16-18G cannula, aspirate <2.5L
  • if success (rib less than 2cm and breathing improved) then consider discharge
  • if not a success chest drain and admit
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16
Q

Describe the management of a secondary pneumothorax

A
  • secondary pneumothorax and less than 2cm, check if the size is 1-2cm
  • if no - admit to high flow oxygen and observed for 24 hours
  • if yes aspirate with a 16-18G cannula, and aspirate at less than 2.5L
  • if this is a success admit, high flow oxygen and observe for 24 hours
  • if this isn’t a success, chest drain and admit

Secondary pneumothorax and greater than 2cm and/or breathless
- chest drain and admit

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17
Q

describe how you manage a chest drain

A
  • Underwater seal drainage
  • Don’t lift bottle above waist
    Retrograde entry of fluid/air into pleural space
  • Never clamp a bubbling chest drain = TENSION PNEUMOTHORAX
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18
Q

What are the symptoms of a tension pneumothorax

A
  • Severe breathlessness
  • Tachycardia
  • Pulsus paradoxus
  • Distended jugular veins
  • Tracheal deviation
  • Ipsilateral reduced/absent
    breath sounds
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19
Q

describe the pathophysiology of a tension pneumothorax

A

On inspiration air goes out of the lung into the pleural space (-ve intrathoracic pressure)
- then on expiration air cannot get back into the lung resulting in positive intrathoracic pressure

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20
Q

What are the symptoms of a tension pneumothorax

A
  • One-way valve
  • Shift in mediastinum
  • Reduced venous return
  • Hypotension
  • Cardiac arrest
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21
Q

How do you treat a tension pneumothorax

A
  • Don’t wait for CXR
  • Needle decompression
  • Large bore cannula (14 G)
  • Mid clavicular line, 2nd intercostal space
  • Hiss of air as you release the tension
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22
Q

where do you put the needle in a tension pneumothorax

A
  • Large bore cannula (14 G)

- Mid clavicular line, 2nd intercostal space

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23
Q

What advice should you give someone who has a pneumothorax

A
  • no diving
  • stop smoking
  • no aeroplane travel for at least 2-6 weeks
  • pregnancy can increase risk of recurrence - monitor closely
  • return immediately if any shortness of breath or chest pain recurs
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24
Q

What is the risk of recurrence in a primary pneumothorax

A

Primary pneumothorax

- 33% to 40% risk of recurrence after first pneumothorax

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25
Q

What is the risk of a recurrence in a secondary pneumothorax

A

Recurrence 39-47%

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26
Q

what is the mortality for pneumothorax

A
  • 0.62/million per year for women

- 1.26/million per year for men

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27
Q

What is the definition of a pulmonary embolism

A

Obstruction of pulmonary arterial system due to Thrombi from distant vein

28
Q

what are the two types of PE

A
  • provoked

- unprovoked

29
Q

What is a provoked PE

A
  • due to a transient risk factor
  • within the last 3 months
  • removing this will reduce risk of recurrence
30
Q

what is an unprovoked PE

A
  • no transient risk factor
  • persistent risk factor which is not correctable
  • increased risk of recurrence
31
Q

What is the difference between provoked and unprovoked PE

A

Provoked

  • due to a transient risk factor
  • within the last 3 months
  • removing this will reduce risk of recurrence

Unprovoked PE

  • no transient risk factor
  • persistent risk factor which is not correctable
  • increased risk of recurrence
32
Q

describe the pathophysiology of a PE

A
  • 75% thrombi formed in deep venous system of lower limbs and pelvis
  • Other sites – upper limbs, cerebral veins, splanchnic veins
  • Platelet aggregation around venous valve sinuses
  • Clotting cascade activated
33
Q

What happens to the lung tissue in an PE

A
  • Lung tissue is ventilated but not perfused
  • Intra-pulmonary dead space
  • Impaired gas exchange - reduced oxygenation
  • Lung tissue can infarct
  • reduces cross section of pulmonary arterial bed
  • increases PA pressure
  • decrease in cardiac output as RV tries to overcome the increase in after load
34
Q

what are non thrombotic emboli

A

Tumours
- esp prostate & breast

Fat
- long-bone fracture

Amniotic fluid in pregnancy

Sepsis

  • tricuspid valve endocarditis : illicit IV drug use
  • infected indwelling catheters
  • pacemaker wires

Foreign bodies

  • Illicit IV drug use
  • Vena cava filters
  • Endovascular stent components
  • Air (during surgery/ trauma)
35
Q

What are the major risk factors for a VTE

A

DVT
- >30% have PE

Previous VTE

Significant immobility
- Inpatient/ bedrest

Surgery (within 2 months)
- Orthopaedic highest

Malignancy

  • 4x higher risk
  • highest - brain cancer

Pregnancy
- especially 6 weeks post party

Lower limb trauma/fracture

36
Q

What are some other risk factors

A
  • > 60 years old

Oral contraception/ HRT
- Within last 6 weeks – 3 months

Significant comorbidity
- Including acute infection/ inflammation

Long distance sedentary
travel

Varicose veins

Superficial venous thrombosis
Known thrombophilias

37
Q

describe THROMBOSIS risk factor analogy

A
  • Travel
  • Hypercoaguable/HRT
  • Recreational drugs
  • Old (>60)
  • Malignancy
  • Birth control pill
  • Obesity/obstetrics
  • Surgery/smoking
  • Immobilization
  • Sickness (CHF/MI, IBD, nephrotic syndrome, vasculitis
38
Q

What is the clinical symptoms of a PE (non massive)

A
  • May be asymptomatic
  • SOB
  • pleuritic chest pain
  • Haemoptysis = may be delayed by 3 days or more
39
Q

What are the clinical signs of a PE (non massive)

A
  • Tachypnoea (85%)
  • Low grade fever (40%)
  • Sinus tachycardia (30%)/new AF
  • Hypoxia
  • Localised pleural rub
  • DVT
  • hypotension
  • raised JVP
  • pleural effusion
40
Q

what is the clinical presentation of a massive PE

A

Hypotension, collapse, cardiac arrest, sudden death
Hypoxia

Acute right heart strain
- loud P2, splitting of 2nd heart sounds, gallop rhythm, tricuspid regurgitation

Right heart failure
- Low cardiac output, raised JVP, low blood pressure

41
Q

How do you diagnose a PE

A
  • History and examination
  • Pre-test probability scoring
  • CXR (usually normal)
  • ECG (usually sinus tachy)
  • Bloods (+/- D dimer)
  • Arterial blood gases (20% of PE normal PaO2)
  • Computed tomographic pulmonary angiography
  • Ventilation:Perfusion scan
  • Echo
42
Q

what is the gold standard for diagnosis for a PE

A
  • Computed tomographic pulmonary angiography

- greater than 95% sensitivity

43
Q

What is the differential diagnosis for PE

A

Respiratory

  • Pneumothorax
  • Pneumonia
  • Acute exacerbation of respiratory disease

Cardiovascular

  • Acute coronary syndrome/ MI
  • Pericarditis
  • Aortic dissection/aneurysm rupture
  • Cardiac tamponade

Other causes of collapse

  • arrhythmia
  • seizures
  • syncope

Others

  • musculoskeletal pain - chest wall tenderness in 20% of people with PE
  • GORD
  • panic attack
44
Q

Who should you admit immediately if suspected PE

A

Admit immediately if suspected PE and:

Haemodynamically unstable
+/-
Pregnant
- Fatal in almost 15%
- 66% of these will die within 30 minutes of the embolic event
- No evidence for using Well’s score in pregnancy
- D-dimer – false positive

45
Q

what makes up the wells score

A
  • Clinical DVT = 3
  • PE is number 1 diagnosis of equally likely = 3
  • heart rate is greater than 100 = 1.5
  • immobilisation for 3 days or surgery in the last 4 weeks = 1.5
  • previous PE/DVT = 1.5
  • haemopytsis = 1
  • malignancy with treatment within 6 months or palliative = 1
46
Q

What should you do once you have calculated the wells score

A

If the score is greater than 4

  • CPTA – if there is a delay in getting CPTA then interim anticoagulation should be given
  • Anticoagulation is given such as a DOAC if CPTA positive – either apixaban or rivaroxaban if these are not suitable then wither LMWH followed by dabigatran or edoxaban or LMWH followed by vitamin K antagonists
  • If CPTA negative then consider a proximal leg vein ultrasound scan if DVT suspect

If the score is less than 4

  • D dimer
  • If D dimer is negative look for alterative diagnose s
  • If D dimer positive – CPTA and anticoagulation
47
Q

What does a CXR look like in a PE

A
  • Usually normal
    Possible signs of
  • pulmonary hypertension (enlarged pulmonary vessels)
  • pleural effusions

Westermark’s sign

  • focal peripheral hyper lucency secondary to oligaemia
  • central pulmonary vessels may be dilated
  • Wedge shaped infarcts
48
Q

What is westermark’s sign

A

Left mid/upper zone regional lucency with truncation of normal left-sided pulmonary markings. Bilateral pleural effusions

49
Q

What is Hamptons hump

A

Wedge-shaped infarct

Peripheral wedge of airspace opacity in the right middle zone

50
Q

What does an ECG look like in PE

A
  • Sinus tachycardia
  • New AF
  • RBBB
  • Peaked T waves
  • R ventricular strain – ant T wave inversion
  • S1Q3T3 = but rare
  • could be normal
51
Q

when should you do imaging for PE

A

Imaging within 1 hour (massive), 24 hours (non-massive)

52
Q

when should V/Q scanning be used for PE

A

Only used if :

  • Normal CXR
  • No concurrent symptomatic cardiovascular disease
  • Used in renal impairment as this does not require the use of contrast unlike CTPA
53
Q

What should you do if you suspect PE in pregnancy

A
  • Well’s score and D-dimer unhelpful
  • Start LMWH
  • CXR (with lead protection for foetus)
  • ECG
  • Bilateral leg ultrasounds – if positive, treat
  • VQ – lower risk for breast cancer(when pregnant, increased risk from radiation) BUT higher risk of childhood cancer (absolute risk minimal)
  • But CTPA more definitive
  • Warfarin contraindicated in pregnancy, but safe with breastfeeding
  • Novel oral anticoagulants can be considered
  • Continue antcoagulation for at least 6 weeks postnatally (at least 3 months total)
54
Q

When should you use an echo to diagnose a PE

A
  • In massive PEs - used when it is unsafe to proceed to CT

- Bedside Echo - right ventricular pressure raised

55
Q

What is the medical management of PE

A

Anticoagulation

  • Heparin
  • Oral anticoagulant

Thrombolysis
- Massive PE, haemodynamic instability

56
Q

what is the invasive treatment for a massive PE

A
  • Embolectomy
  • Mechanical fragmentation with R heart angiography
  • Pulmonary thrombo-
    endarterectomy
    chronic PE’s unresolved after 3 months
  • Inferior vena cava filter
57
Q

What should you do if you have a suspected non massive PE (management)

A 
Low molecular weight heparin (LMWH) 
OR
 fondaparinux 
OR
 unfractionated heparin (UFH)
- Incr bleeding risk
- Regular blood tests
- Rapid reversal possible
- More rapid anticoagulation
58
Q

What should you do if you have a confirmed non massive PE which is haemodynamically stable

A 
UFH/LMWH/fondaparinux lead in + Warfarin
- Target INR 2-3 
- then stop heparin
OR
Direct oral anticoagulant with or without LMWH lead-in
59
Q

How long should you use oral anticoagulation for

A

Provoked Reversible

  • 3 months - orthopaedic surgery, trauma, CVC line
  • 3-12 months - OCP, Flights, HRT, immobility, pregnancy

Provoked irreversible/unprovoked/recurrent
- indefinite

60
Q

what is an inferior vena cava filter

A
  • used if you cannot use anticoagulation in proximal PE/DVT
  • recurrent VTE despite anticoagulation despite alternatives (LMWH or higher INR target)
  • temporary
61
Q

What should you consider with an unprovoked PE

A

CONSIDER CANCER

62
Q

What investigations should you use to look for cancer after an unprovoked PE

A
  • History and examination
  • Bloods – incl calcium, FBC, - LFT
  • CXR
  • Urinalysis
  • If > 40 ? abdo-pelvic CT + mammogram
  • +/- antiphospholipid testing
  • Thrombophilia testing (first-degree relative with VTE)
63
Q

What is the prognosis of a massive PE

A

20% mortality following treatment (18-65% overall)

64
Q

What is the prognosis of a non massive PE

A

Death rate <5% in first 3-6 months

30% of people with VTE have recurrence within 10 years

65
Q

what do you use to thrombolyse a massive PE

A
  • when haemodynamically unstable you should thrombolyse for massive PE
  • alteplase 10mg IV over 1 minute then 90mg IV over 2 hours
66
Q

When do you thrombolyse in PE

A
  • Thrombolysis is now recommended as the first line treatment for massive PE when there is circulatory failure (e.g. hypotension)

Year 3 - CR (44 decks)

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