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Yr 4 - ACC > Respiratory: Pneumothorax, PE & Pneumonia > Flashcards

Respiratory: Pneumothorax, PE & Pneumonia Flashcards

1
Q

What is a pneumothorax?

A

Air in pleural space - separating lung from chest wall

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2
Q

What are the 2 major classifications of a pneumothorax?

A

Spontaneous & 2ary (to trauma, medical interventions i.e. iatrogenic, or lung pathology)

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3
Q

Typical patient with a pneumothorax in exams?

A

A tall, thin, young man presenting with sudden breathlessness and pleuritic chest pain, possibly whilst playing sports.

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4
Q

Causes of a pneumothorax?

A
  • Spontaneous
  • Trauma
  • Iatrogenic, for example, due to lung biopsy, mechanical ventilation or central line insertion
  • Lung pathologies such as infection, asthma or COPD
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5
Q

Give some underlying pathologies that can lead to 2ary spontaneous pneumothorax’s

A
  • Connective tissue disease e.g. Marfan’s syndrome, Ehlers-Danlos syndrome
  • Obstructive lung disease e.g. asthma, COPD
  • Infective lung disease e.g. TB, pneumonia
  • Fibrotic lung disease e.g. cystic fibrosis, idiopathic pulmonary fibrosis
  • Neoplastic disease e.g. bronchial carcinoma
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6
Q

Traumatic pneumothorax’s can be classified into iatrogenic and non-iatrogenic causes.

Give some examples for both

A

Iatrogenic –> central line insertion, positive pressure ventilation, lung biopsy

Non-iatrogenic –> penetrating trauma, blunt trauma with rib fracture

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7
Q

Give some symptoms of a pneumothorax

A
  • Sudden onset SOB
  • Pleuritic chest pain
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8
Q

How is each factor affected in a pneumothorax:

a) Chest expansion
b) Percussion
c) Breath sounds
d) Vocal resonance

A

a) reduced on affected side

b) hyperresonant on affected side

c) reduced/absent on affected side with no added sounds

d) reduced on affected side

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9
Q

What is the 1st line investigation in a pneumothorax?

A

CXR

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10
Q

How is patient positioned in a CXR for a simple pneumothorax?

A

Erect (i.e. standing)

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11
Q

CXR findings in a pneumothorax?

A

It shows an area between the lung tissue and the chest wall with no lung markings. There will be a line demarcating the edge of the lung where the lung markings end and the pneumothorax begins.

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12
Q

How is a pneumothorax measured in size on a CXR?

A

Measuring horizontally from the lung edge to the inside of the chest wall at the level of the hilum (see zero to finals).

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13
Q

What imaging can be used to detect a pneumothorax that is too small to be seen on a chest x-ray?

A

CT thorax

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14
Q

What imaging can be used to measure the size of a pneumothorax ACCURATELY?

A

CT thorax

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15
Q

Management of pneumothorax that is less than a 2cm rim of air on the CXR and there is no SOB?

A

No treatment is required as it will spontaneously resolve

Follow-up in 2 – 4 weeks is recommended

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16
Q

Management of a pneumothorax that is more than a 2cm rim of air on the CXR and there is SOB?

A

Aspiration followed by reassessment

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17
Q

If aspiration fails in a pneumothorax, what is the next step?

A

Chest drain

N.B. Unstable patients, bilateral or secondary pneumothoraces, generally require a chest drain.

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18
Q

What type of cannula is used to aspirate a pneumothorax?

A

A 16-18G cannula under local anaesthetic

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19
Q

Where is a chest drain located in a pneumothorax?

A

Triangle of safety

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20
Q

What is the triangle of safety formed by (3 borders)?

A

1) 5th intercostal space (or inferior to nipple)

2) Midaxillary line (or lateral edge of latissimus dorsi)

3) Anterior axillary line (or lateral edge of pectoralis major)

See zero to finals for picture

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21
Q

Is the needle inserted above or below the rib when inserting a chest drain in a pneumothorax?

A

The needle is inserted just above the rib to avoid the neurovascular bundle that runs just below the rib.

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22
Q

Once the chest drain has been inserted in a pneumothorax, what should you do?

A

Get a CXR to check positioning

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23
Q

How does a chest drain work in treating a pneumothorax?

A

1) The external end of the drain is placed underwater, creating a seal to prevent air from flowing back through the drain into the chest.

2) Air can exit the chest cavity and bubble through the water, but the water prevents air from re-entering the drain and chest.

3) During normal respiration, the water in the drain will rise and fall due to changes in pressure in the chest (described as “swinging”).

4) When the chest drain successfully treats the pneumothorax, air will bubble through the fluid in the drain bottle

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24
Q

How to know when a chest drain has successfully treated a pneumothorax?

A

1) There will be swinging of the water with respiration

2) On a repeat CXR there will be reinflation of the lung

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25
Q

If a chest drain does not appear to have successfully treated a pneumothorax, what may be the problem?

A

1) Blocked or kinked tube

2) Incorrect position in the chest

3) Not correctly connected to the bottle

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26
Q

What are 2 key complications of chest drains?

A

1) Air leaks around the drain site (indicated by persistent bubbling of fluid, particularly on coughing)

2) Surgical emphysema (also known as subcutaneous emphysema) is when air collects in the subcutaneous tissue

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27
Q

What may indicate an air leak in a chest drain?

A

Persistent bubbling of fluid, particularly on coughing

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28
Q

What is a surgical/subcutaneous emphysema?

A

when air collects in the subcutaneous tissue

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29
Q

When may patients require SURGICAL interventions for a pneumothorax?

A

1) A chest drain fails to correct the pneumothorax

2) There is a persistent air leak in the drain

3) The pneumothorax reoccurs (recurrent pneumothorax)

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30
Q

What surgical method is used to correct a pneumothorax?

A

Video-assisted thoracoscopic surgery (VATS)

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31
Q

What are the 3 surgical options for pneumothorax?

A

1) Abrasive pleurodesis (using direct physical irritation of the pleura)

2) Chemical pleurodesis (using chemicals, such as talc powder, to irritate the pleura)

3) Pleurectomy (removal of the pleura)

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32
Q

What is pleurodesis?

A

Pleurodesis involves creating an inflammatory reaction in the pleural lining so the pleura STICKS together and the pleural space becomes SEALED.

This prevents further pneumothoraces from developing.

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33
Q

What is a tension pneumothorax?

A

Caused by trauma to the chest wall that creates a ONE-WAY valve that lets air IN but not OUT of the pleural space.

Therefore, with each breath, more air is drawn into the pleural space and cannot escape.

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34
Q

Why is tension pneumothorax an emergency condition?

A

It creates pressure inside the thorax to push the mediastinum across, kink the big vessels in the mediastinum and cause cardiorespiratory arrest.

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35
Q

Signs of a tension pneumothorax?

A
  • Tracheal deviation away from the side of the pneumothorax
  • Reduced air entry on the affected side
  • Increased resonance to percussion on the affected side
  • Tachycardia
  • Hypotension
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36
Q

Management of a tension pneumothorax?

A

ABCDE approach

Insert a LARGE BORE cannula into the 2nd intercostal space in the midclavicular line (just above the third rib).

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37
Q

What is pneumonia?

A

Pneumonia is an infection of the lung tissue, causing inflammation in the alveolar space.

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38
Q

How is pneumonia seen on a CXR?

A

Consolidation

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39
Q

Define acute bronchitis

A

Acute bronchitis refers to infection and inflammation in the bronchi and bronchioles.

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40
Q

Is acute bronchitis a LRTI or URTI?

A

LRTI

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41
Q

Are LRTIs or URTIs more likely to be viral?

A

Upper respiratory tract infections (e.g., a common cold) are usually viral.

As a general rule, the lower down the respiratory tract, the higher the probability of bacterial infection, as opposed to viral.

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42
Q

What are the 4 classifications of pneumonia?

A

1) Community-acquired pneumonia (CAP)

2) Hospital-acquired pneumonia (HAP)

3) Ventilator-acquired pneumonia (VAP)

4) Aspiration pneumonia

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43
Q

When does HAP develop?

A

Develops after more than 48 hours in a hospital

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44
Q

Who does VAP develop in?

A

Develops in intubated patients in the intensive care unit

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45
Q

What is aspiration pneumonia?

A

Aspiration pneumonia is when the infection develops due to the aspiration of food or fluid

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46
Q

Who is aspiration pneumonia common in?

A

Impaired swallowing e.g. stroke, advanced dementia

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47
Q

What type of bacteria is aspiration pneumonia associated with?

A

Anaerobic bacteria

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48
Q

Symptoms of pneumonia?

A
  • Cough
  • Sputum production
  • Shortness of breath
  • Fever
  • Feeling generally unwell
  • Haemoptysis (coughing up blood)
  • Pleuritic chest pain (sharp chest pain, worse on inspiration)
  • Delirium (acute confusion)
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49
Q

Auscultation findings in pneumonia?

A

1) Bronchial breath sounds –> due to consolidation around the airways

2) Focal coarse crackles –> caused by air passing through sputum in the airways

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50
Q

Describe bronchial breath sounds

A

Harsh inspiratory and expiratory breath sound

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51
Q

Percussion findings in pneumonia?

A

Dullness –> due to lung tissue filled with sputum or collapsed

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52
Q

What signs may indicate SEPSIS 2ary to pneumonia?

A
  • Tachycardia
  • Tachypnoea
  • Hypoxia (low oxygen)
  • Hypotension (shock)
  • Fever
  • Confusion
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53
Q

When should the CRB-65 scoring system be used in pneumonia be used? When should CURB-65 be used?

A

CRB-65: out of hospital
CURB-65: in hospital

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54
Q

What CRB-65 score indicates the need to consider hospital assessment?

A

Score more than 0

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55
Q

Describe the CURB-65

A

Confusion
Urea >7 mmol/L
Respiratory rate >/= 30
BP <90 systolic or </= 60 diastolic
Age >/= 65

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56
Q

What does a CURB-65 score of 0 or 1 indicate?

A

Consider treatment at home

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57
Q

What does a CURB-65 score of >/=2 indicate?

A

Consider hospital admission

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58
Q

What does a CURB-65 score of >/= 3 indicate?

A

Consider intensive care

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59
Q

What is the most common causative organism of pneumonia

A

Streptococcus pneumoniae (pneumococcus)

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60
Q

What organism typically causes pneumonia in COPD patients?

A

Haemophilus influenzae

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61
Q

Give some causes of typical pneumonia?

A

1) Strep. pneumoniae
2) Haemophilus influenzae
3) Moraxella catarrhalis
4) Pseudomonas aeruginosa
5) Staphylococcus aureus
6) Methicillin-resistant Staphylococcus aureus (MRSA)
7) Klebsiella pneumoniae

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62
Q

What is an atypical pneumonia?

A

Atypical pneumonia is caused by organisms that cannot be cultured in the normal way or detected using a gram stain.

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63
Q

What are the organisms causing atypical pneumonias?

A

1) Legionella pneumophila (Legionnaires’ disease)

2) Mycoplasma pneumoniae

3) Chlamydophila pneumoniae

4) Coxiella burnetii, or Q fever

5) Chlamydia psittaci

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64
Q

Which causative organism of pneumonia is particularly associated with high fever, rapid onset and herpes labialis?

A

Streptococcus pneumoniae (pneumococcus)

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65
Q

Which type of pneumonia often occurs in patients following influenza infection?

A

Staph. aureus

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66
Q

What 2 organisms typically cause pneumonia in cystic fibrosis patients?

A

1) Pseudomonas aeruginosa

2) Staphylococcus aureus

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67
Q

When does MRSA typically cause pneumonia?

A

In hospital-acquired infections

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68
Q

What organism typically causes pneumonia in immunocompromised patients or those with chronic pulmonary disease?

A

Moraxella catarrhalis

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69
Q

What organism typically causes pneumonia in patients with cystic fibrosis or bronchiectasis?

A

Pseudomonas aeruginosa

70
Q

What is Legionella pneumophila typically caused by?

A

Typically caused by inhaling infected water from infected water systems, such as air conditioning units.

71
Q

Which type of pneumonia causes hyponatraemia? Why?

A

Legionella pneumophilia - can cause a syndrome of inappropriate ADH (SIADH), resulting in hyponatraemia

72
Q

Typical patient with Legionella pneumophila?

A

The typical exam patient has recently had a cheap hotel holiday and presents with pneumonia symptoms and hyponatraemia.

73
Q

Initial screening test for Legionella pneumophila (Legionnaires’ disease)?

A

A urine antigen test

74
Q

What type of pneumonia can cause SIADH?

A

Legionella pneumophila (Legionnaires’ disease)

75
Q

Which organism can cause erythema multiforme?

A

Mycoplasma pneumoniae

76
Q

What is erythema multiforme?

A

Rash characterised by varying-sized “target lesions” formed by pink rings with pale centres

77
Q

What type of severity of pneumonia does Mycoplasma pneumoniae cause?

A

Milder pneumonia

78
Q

What type of pneumonia can cause neurological symptoms in young patients?

A

Mycoplasma pneumoniae

79
Q

What type of pneumonia often present a dry cough and atypical chest signs/x-ray findings. Autoimmune haemolytic anaemia and erythema multiforme may be seen?

A

Mycoplasma pneumoniae

80
Q

What type of pneumonia can cause autoimmune haemolytic anaemia?

A

Mycoplasma pneumoniae

81
Q

What type of pneumonia causes mild to moderate chronic pneumonia and wheezing in school-age children?

A

Chlamydophila pneumoniae

Be cautious, as this presentation is common without chlamydophila pneumoniae infection.

82
Q

What type of pneumonia is linked to exposure to the bodily fluids of animals?

A

Coxiella burnetii, or Q fever

The typical exam patient is a farmer with a flu-like illness.

83
Q

What type of pneumonia is typically contracted from contact with infected birds?

A

Chlamydia psittaci

The typical exam patient is a parrot owner.

84
Q

Pneumonic for remembering the 5 causes of atypical pneumonia:

“Legions of psittaci MCQs”

A

Legions – Legionella pneumophila
Psittaci – Chlamydia psittaci
M – Mycoplasma pneumoniae
C – Chlamydophila pneumoniae
Qs – Q fever (coxiella burnetii)

85
Q

What type of pneumonia is classically seen in alcoholics or diabetes?

A

Klebsiella pneumoniae

86
Q

What is Pneumocystis jirovecii pneumonia (PCP)?

A

a fungal pneumonia

87
Q

Who does Pneumocystis jirovecii pneumonia typically occur in?

A

Immunocompromised patients e.g. poorly controlled HIV

88
Q

How does Pneumocystis jirovecii pneumonia typically present?

A
  • Dry cough
  • SOB on exertion (and exercise-induced desaturations)
  • Night sweats
  • Absence of chest signs
89
Q

What is the treatment for Pneumocystis jirovecii pneumonia?

A

Co-trimoxazole (trimethoprim/sulfamethoxazole) i.e. Septrin

Patients with a low CD4 count are prescribed prophylactic co-trimoxazole to protect against PCP.

90
Q

The covid-19 virus (SARS-CoV-2) can cause pneumonia.

Symptoms?

A
  • Anosmia (loss of smell)
  • Patients may not feel particularly short of breath despite having low oxygen saturations (“silent hypoxia”)
91
Q

Management of COVID-19 pneumonia?

A

Respiratory support (e.g., oxygen), dexamethasone and monoclonal antibodies.

92
Q

What is idiopathic interstitial pneumonia?

A

Idiopathic interstitial pneumonia is a group of non-infective causes of pneumonia.

E.g. cryptogenic organizing pneumonia –> a form of bronchiolitis that may develop as a complication of rheumatoid arthritis or amiodarone therapy

93
Q

Classical CXR finding in pneumonia?

A

Consolidation

94
Q

Investigations in pneumonia for patients admitted to hospital?

A

Patients in the community with CRB 0 or 1 pneumonia do not necessarily need investigations.

  • CXR
  • FBC
  • Renal profile i.e. U&Es
  • CRP (raised)
  • ABG (if low O2 sats or patient has pre-existing respiratory disease e.g. COPD)

Patients with moderate or severe infection will also have:

1) Sputum cultures
2) Blood cultures
3) Pneumococcal and Legionella urinary antigen tests

95
Q

FBC in bacterial pneumonia?

A

Neutrophilia (raised WCC)

96
Q

How can WCC and CRP indicate severity of infection?

A

White blood cells and CRP are raised roughly in proportion to the severity of the infection.

97
Q

When does CRP rise in relation to WCC?

A

CRP starts rising 6 hours behind the onset of inflammation and peaks after 24-48 hours. It may initially be low before becoming very high a day or two later.

98
Q

When does CRP peak?

A

After 24-48 hours

99
Q

Management of pneumonia?

A

1) Antibiotics (follow local guidelines)

2) Supportive care

100
Q

1st line Abx in the management of low-severity community-acquired pneumonia?

A

Typical pneumonia –> amoxicillin

Atypical –> macrolides (e.g. clarithromycin), fluoroquinolones (e.g. levofloxacin), and tetracyclines (e.g. doxycycline)

Typically treated with 5 day course of Abx

101
Q

If patient is pencillin allergic, what Abx can be given in pneumonia?

A

macrolide (e.g. clarithromycin) or tetracycline (e.g. doxycycline)

102
Q

Management of moderate and high-severity community acquired pneumonia?

A
  • DUAL Abx therapy is recommended with amoxicillin and a macrolide e.g. co-amoxiclav + clarithromycin
  • A 7-10 day course is recommended
  • Usually treated initially with intravenous antibiotics and stepped down to oral antibiotics as the condition improves
  • Respiratory support (e.g., oxygen or intubation and ventilation)
103
Q

When should all cases of pneumonia have a repeat CXR?

A

6 weeks after clinical resolution to ensure that the consolidatoin has resolves and there is no underlying secondary abnormalities (e.g. a lung tumour).

104
Q

Complications of pneumonia?

A

Sepsis
Acute respiratory distress syndrome
Pleural effusion
Empyema
Lung abscess
Death

105
Q

Pathophysiology of pneumonia?

A
  1. Inflammation leads to fluid and blood cells leaking into the alveoli.
  2. The infection spreads across the alveoli and eventually the lung tissue becomes consolidated, impairing the gas exchange due to reduced ventilation.
106
Q

what is a pleural rub? cause?

A

An audible sound heard in patients with pleurisy

Caused by layers of pleura rubbing against each other

107
Q

Why is a urine sample for antigen testing required in pneumonia?

A

To distinguish between legionella and pneumococcal urinary antigens

108
Q

After how many days of starting Abx should inflammatory markers be repeated in pneumonia?

A

3 days

109
Q

Top 3 causative organisms of hospital acquired pneumonia?

A

1) Pseudomonas aeruginosa
2) Staph. aureus
3) Enterobacteria

110
Q

Risk factors for aspiration pneumonia?

A
  • Myasthenia gravis
  • Bulbar palsy
  • Alcoholism
  • Achalasia
  • Poor dental hygiene
111
Q

Which lung is more affected in aspiration pneumonia? Why?

A

R lung more affected due to R bronchus being more vertical and wider

112
Q

What patient is chlamydophila pnuemoniae typically seen in?

A

School aged child with mild to moderate chronic pneumonia and wheeze

113
Q

What is a pulmonary embolism (PE)?

A

A blood clot (thrombus) in the pulmonary arteries.

The thrombus will block the blood flow to the lung tissue and strain the right side of the heart. DVTs and PEs are collectively known as venous thromboembolism (VTE).

114
Q

What is an embolus?

A

An embolus is a thrombus that has travelled in the blood, often from a deep vein thrombosis (DVT) in a leg.

115
Q

Risk factors for PE?

A
  • Immobility
  • Recent surgery
  • Recent long-haul travel
  • Hormone therapy with oestrogen (e.g. COCP, HRT)
  • Malignancy
  • Pregnancy
  • Polycythaemia (raised haemoglobin)
  • Systemic lupus erythematosus
  • Thrombophilia

In your exams, when a patient presents with possible features of a DVT or PE, ask about risk factors such as periods of immobility, surgery and long-haul flights to score extra points.

116
Q

How is the risk of VTE reduced in patients undergoing surgery?

A

prophylactic treatment

117
Q

Every patient admitted to hospital is assessed for their risk of venous thromboembolism (VTE).

What is the prophylaxis for higher-risk patients?

A

1) Low molecular weight heparin (e.g., enoxaparin) unless contraindicated

2) Anti-embolic compression stockings unless contraindicated

118
Q

Contraindications for VTE prophylaxis (heparin)?

A
  • Active bleeding
  • Existing anticoagulations e.g. warfarin, DOAC
119
Q

Contraindication for anti-embolic compression stockings?

A

Peripheral arterial disease (PAD)

120
Q

Presentation of a PE?

A
  • Can be asymptomatic and discovered incidentally (present with subtle signs and symptoms, or even cause sudden death)
  • SOB
  • Cough
  • Haemoptysis (coughing up blood)
  • Pleuritic chest pain (sharp pain on inspiration)
  • Hypoxia
  • Tachycardia
  • Raised respiratory rate
  • Low-grade fever
  • Haemodynamic instability causing hypotension

There may also be signs and symptoms of a deep vein thrombosis, such as unilateral leg swelling and tenderness.

121
Q

Typical triad of symptoms in PE?

A

1) Pleuritic chest pain
2) Haemoptysis
3) Dyspnoea

However, few patients (10%) present this way - often difficult to diagnose

122
Q

4 most common clinical signs in PE?

A

1) Tachypnea (respiratory rate >16/min) - 96%
2) Crackles - 58%
3) Tachycardia (heart rate >100/min) - 44%
4) Fever (temperature >37.8°C) - 43%

It is interesting to note that the Well’s criteria for diagnosing a PE use tachycardia rather than tachypnoea.

123
Q

What is the pulmonary embolism rule-out criteria (PERC)?

When is it used?

A

The pulmonary embolism rule-out criteria (PERC) are recommended by the NICE when the clinician estimates LESS THAN A 15% probability of a PE to decide whether further investigations for a PE are needed.

If all the criteria are met, further investigations for a PE are NOT required.

124
Q

If all criteria of the PERC are met, what happens?

A

If ALL the criteria are met (i.e. absent), further investigations for a PE are NOT required.

125
Q

When should PERC be used?

A

This should be done when you think there is a low pre-test probability of PE (<15%) , but want more reassurance that it isn’t the diagnosis

126
Q

What are the PERC?

A

1) Age >/= 50
2) Heart rate >/= 100
3) O2 sats (</= 94%)
4) Previous DVT or PE
5) Recent surgery or trauma in the past 4 weeks
6) Haemoptysis
7) Unilateral leg swelling
8) Oestrogen use (e.g. HRT and contraceptives)

127
Q

When should a Wells score be performed?

A

If a PE IS suspected (instead of PERC)

128
Q

What Wells score indicates a PE is likely?

A

> 4

129
Q

What Wells score indicates a PE is unlikely?

A

4 or less

130
Q

If the Wells score is >4 (PE is likely), what is the next step?

A

Perform a CT pulmonary angiogram (CTPA) or alternative imaging

If positive –> PE diagnosed
If negative –> consider proximal leg US if DVT suspected

131
Q

Why should a CXR be performed in PE?

A

A chest x-ray is usually normal in a pulmonary embolism but is required to rule out other pathology.

132
Q

What are the three imaging options for establishing a diagnosis of a pulmonary embolism?

A

1) CT pulmonary angiogram –> the usual first-line
2) Ventilation-perfusion single photon emission computed tomography (V/Q SPECT) scan
3) Planar ventilation–perfusion (VQ) scan

133
Q

If the Wells score is </= 4 (PE is unlikely), what is the next step?

A

Perform a d-dimer (with result within 4 hours)

134
Q

If the d-dimer result is positive in a PE, what is the next step?

A

Perform a CTPA

If positive –> PE diagnosed
If negative –> consider proximal leg US if DVT suspected

135
Q

What is a d-dimer test?

A

D-dimer is a sensitive (95%) but not a specific blood test for VTE.

It helps exclude VTE where there is a low suspicion. It is almost always raised if there is a DVT.

136
Q

What other conditions can cause a raised d-dimer?

A

Pneumonia
Malignancy
Heart failure
Surgery
Pregnancy

137
Q

If d-dimer is negative in suspcted PE, what is next step?

A

Consider alternative diagnosis and stop anticoagulation

138
Q

What is a CT pulmonary angiogram (CTPA)?

A

A chest CT scan with an IV contrast that highlights the pulmonary arteries to demonstrate any blood clots.

139
Q

1st line imaging in PE? Why?

A

CTPA

This is readily available, provides a more definitive assessment and gives information about alternative diagnoses, such as pneumonia or malignancy.

140
Q

What is a ventilation-perfusion (VQ) scan?

A

Involves using radioactive isotopes and a gamma camera to compare ventilation with the perfusion of the lung.

141
Q

When would a VQ scan be indicated over a CTPA in a PE?

A

1) renal impairment (due to contrast in CTPA)
2) contrast allergy
3) risk from radiation

142
Q

How does a VQ scan work in PE?

A

1) First, the isotopes are inhaled to fill the lungs, and a picture is taken to demonstrate ventilation.

2) Next, a contrast containing isotopes is injected, and a picture is taken to illustrate perfusion.

3) The two images are compared.

143
Q

VQ scan in PE?

A

With a PE, there will be a deficit in PERFUSION as the thrombus blocks blood flow to the lung tissue. The lung tissue will be VENTILATED but not PERFUSED. Planar V/Q scans produce 2D images. V/Q SPECT scans produce 3D images, making them more accurate.

144
Q

ABG results in a PE?

A

respiratory alkalosis as hypoxia causes a raised RR

145
Q

Management of a PE?

A

1) Suppirtive maangement (e.g. admission to hospital as required, O2 & analgesia as required)

2) Anticoagulation

146
Q

1st line anticoagulation in PE?

A

DOACs (Apixaban or rivaroxaban)

(LMWH is the main alternative)

147
Q

When should anticoagulation be started in suspected PE patients?

A

This should be started immediately in patients where PE is suspected and there is a delay in getting a scan to confirm the diagnosis.

148
Q

Management of a massive PE with haemodynamic compromise?

A

Continuous infusion of unfractionated heparin and considering thrombolysis.

149
Q

What is thrombolysis?

A

Thrombolysis involves injecting a fibrinolytic (breaks down fibrin) medication that rapidly dissolves clots.

150
Q

Why is thrombolysis only used in patients with a massive PE ?

A

Due to dangers –> significant risk of bleeding with thrombolysis

151
Q

Examples of thrombolytic agents?

A

1) Streptokinase
2) Alteplase
3) Tenecteplase

152
Q

What are the 2 ways that thrombolysis can be performed?

A

1) Intravenously using a peripheral cannula

2) Catheter-directed thrombolysis (directly into the pulmonary arteries using a central catheter)

152
Q

What are the 3 options of long-term anticoagulation in VTE?

A

1) DOAC
2) Warfarin
3) LMWH

153
Q

Examples of DOACs?

A

apixaban, rivaroxaban, edoxaban and dabigatran

154
Q

If patient has active cancer, what is 1st line anticoagulation in PE?

A

DOAC (unless contraindication)

155
Q

How long should patients with a PE have anticoagulation for?

A

At least 3 months

156
Q

What determines whether anticoagulation is carried on longer than 3 months in a PE?

A

whether the VTE was provoked or unprovoked

(if unprovoked, requires longer anticoagulation)

157
Q

What is a provoked VTE?

A

Due to an obvious precipitating event e.g. immobilisation following major surgery

158
Q

What is an unprovoked VTE?

A

Occurs in the absence of an obvious precipitating event, i.e. there is a possibility that there are unknown factors (e.g. mild thrombophilia) making the patient more at risk from further clots

159
Q

When is anticoagultion stopped after a provoked VTE?

What is the exception to this?

A

Typically stopped after the initial 3 months (3 to 6 months for people with active cancer)

160
Q

When is anticoagultion stopped after an unprovoked VTE?

A

treatment is typically continued for up to 3 further months (i.e. 6 months in total)

161
Q

Contraindications to DOACs?

A

1) Severe renal impairment (creatinine clearance less than 15 ml/min)
2) Antiphospholipid syndrome
3) Pregnancy

162
Q

1st line anticoagulant in PE in pregnancy?

A

LMWH

163
Q

Length of anticoagulation following a PE in patients with active cancer?

A

3-6 months

164
Q

Mechanism of warfarin?

A

Vitamin K antagonist –> reduces synthesis of active clotting factors

165
Q

How are warfarin levels monitored?

A

The international normalised ratio (INR) blood test –> tells you how long it takes for your blood to clot.

166
Q

Target INR in people taking warfarin when treating DVTs and PEs?

A

Between 2 and 3

167
Q

1st line anticoagulation in patients with antiphospholipid syndrome?

A

Warfarin (also require initial concurrent treatment with LMWH)

168
Q

Classic ECG changes in PE?

A

1) Large S waves in lead I
2) Large Q waves in lead III
3) Inverted T wave in lead III (only seen in 20% of patients)
4) Can see right bundle branch block and right axis deviation
5) Can see sinus tachycardia

169
Q
A

Yr 4 - ACC (73 decks)

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