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
What is the risk of a recurrence in a secondary pneumothorax
Recurrence 39-47%
26
what is the mortality for pneumothorax
- 0.62/million per year for women | - 1.26/million per year for men
27
What is the definition of a pulmonary embolism
Obstruction of pulmonary arterial system due to Thrombi from distant vein
28
what are the two types of PE
- provoked | - unprovoked
29
What is a provoked PE
- due to a transient risk factor - within the last 3 months - removing this will reduce risk of recurrence
30
what is an unprovoked PE
- no transient risk factor - persistent risk factor which is not correctable - increased risk of recurrence
31
What is the difference between provoked and unprovoked PE
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
describe the pathophysiology of a PE
- 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
What happens to the lung tissue in an PE
- 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
what are non thrombotic emboli
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
What are the major risk factors for a VTE
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
What are some other risk factors
- > 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
describe THROMBOSIS risk factor analogy
- Travel - Hypercoaguable/HRT - Recreational drugs - Old (>60) - Malignancy - Birth control pill - Obesity/obstetrics - Surgery/smoking - Immobilization - Sickness (CHF/MI, IBD, nephrotic syndrome, vasculitis
38
What is the clinical symptoms of a PE (non massive)
- May be asymptomatic - SOB - pleuritic chest pain - Haemoptysis = may be delayed by 3 days or more
39
What are the clinical signs of a PE (non massive)
- Tachypnoea (85%) - Low grade fever (40%) - Sinus tachycardia (30%)/new AF - Hypoxia - Localised pleural rub - DVT - hypotension - raised JVP - pleural effusion
40
what is the clinical presentation of a massive PE
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
How do you diagnose a PE
- 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
what is the gold standard for diagnosis for a PE
- Computed tomographic pulmonary angiography | - greater than 95% sensitivity
43
What is the differential diagnosis for PE
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
Who should you admit immediately if suspected PE
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
what makes up the wells score
- 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
What should you do once you have calculated the wells score
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
What does a CXR look like in a PE
- 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
What is westermark's sign
Left mid/upper zone regional lucency with truncation of normal left-sided pulmonary markings. Bilateral pleural effusions
49
What is Hamptons hump
Wedge-shaped infarct | Peripheral wedge of airspace opacity in the right middle zone
50
What does an ECG look like in PE
- Sinus tachycardia - New AF - RBBB - Peaked T waves - R ventricular strain – ant T wave inversion - S1Q3T3 = but rare - could be normal
51
when should you do imaging for PE
Imaging within 1 hour (massive), 24 hours (non-massive)
52
when should V/Q scanning be used for PE
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
What should you do if you suspect PE in pregnancy
- 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
When should you use an echo to diagnose a PE
- In massive PEs - used when it is unsafe to proceed to CT | - Bedside Echo - right ventricular pressure raised
55
What is the medical management of PE
Anticoagulation - Heparin - Oral anticoagulant Thrombolysis - Massive PE, haemodynamic instability
56
what is the invasive treatment for a massive PE
- Embolectomy - Mechanical fragmentation with R heart angiography - Pulmonary thrombo- endarterectomy chronic PE’s unresolved after 3 months - Inferior vena cava filter
57
What should you do if you have a suspected non massive PE (management)
``` Low molecular weight heparin (LMWH) OR fondaparinux OR unfractionated heparin (UFH) - Incr bleeding risk - Regular blood tests - Rapid reversal possible - More rapid anticoagulation ```
58
What should you do if you have a confirmed non massive PE which is haemodynamically stable
``` UFH/LMWH/fondaparinux lead in + Warfarin - Target INR 2-3 - then stop heparin OR Direct oral anticoagulant with or without LMWH lead-in ```
59
How long should you use oral anticoagulation for
Provoked Reversible - 3 months - orthopaedic surgery, trauma, CVC line - 3-12 months - OCP, Flights, HRT, immobility, pregnancy Provoked irreversible/unprovoked/recurrent - indefinite
60
what is an inferior vena cava filter
- used if you cannot use anticoagulation in proximal PE/DVT - recurrent VTE despite anticoagulation despite alternatives (LMWH or higher INR target) - temporary
61
What should you consider with an unprovoked PE
CONSIDER CANCER
62
What investigations should you use to look for cancer after an unprovoked PE
- 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
What is the prognosis of a massive PE
20% mortality following treatment (18-65% overall)
64
What is the prognosis of a non massive PE
Death rate <5% in first 3-6 months 30% of people with VTE have recurrence within 10 years
65
what do you use to thrombolyse a massive PE
- when haemodynamically unstable you should thrombolyse for massive PE - alteplase 10mg IV over 1 minute then 90mg IV over 2 hours
66
When do you thrombolyse in PE
- Thrombolysis is now recommended as the first line treatment for massive PE when there is circulatory failure (e.g. hypotension)