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Medical Emergencies > Severe Pulmonary Oedema > Flashcards

Severe Pulmonary Oedema Flashcards

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USMLE® Step 1 flashcards
1
Q

What are the causes of severe pulmonary oedema?

A
  • Cardiac cause
  • Adult respiratory distress syndrome
  • Fluid overload
  • Neurogenic
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2
Q

What are the cardiovascular causes of severe pulmonary oedema?

A
  • Usually left ventricular failure, post MI or in ischaemic heart disease
  • Valvular heart disease
  • Arrhythmias
  • Malignant hypertension
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3
Q

Give three examples of things that can cause adult respiratory distress syndrome

A
  • Trauma
  • Malaria
  • Drugs
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4
Q

What can cause neurogenic pulmonary oedema?

A

Head injury

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5
Q

What are the differential diagnoses of severe pulmonary oedema?

A
  • Asthma/COPD
  • Pneumonia
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6
Q

What should you do in an extremely unwell patient when you cannot determine if the cause is pulmonary oedema, pneumonia, or asthma/COPD?

A

Consider treating all 3, e.g. with salbutamol nebulisers, furosemide IV, diamorphine, amoxicillin etc

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7
Q

What are the symptoms of severe pulmonary oedema?

A
  • Dyspnoea
  • Orthopnoea
  • Pink, frothy sputum
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8
Q

What are the signs of severe pulmonary oedema?

A
  • Distressed
  • Pale
  • Sweaty
  • Increased pulse
  • Tachypnoea
  • Pulsus alterans
  • Increased JVP
  • Fine lung crackles
  • Triple/gallop rhythm
  • Wheeze
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9
Q

What investigations should be done in a patient presenting with severe pulmonary oedema?

A
  • CXR
  • ECG
  • U&E
  • Troponin
  • ABG
  • Consider echo
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10
Q

What might the chest x-ray show in severe pulmonary oedema?

A
  • Cardiomegaly
  • Shadowing, usually bilateral
  • Small effusions at costophrenic angles
  • Fluid in lung fissures
  • Kerley B lines
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11
Q

How should severe pulmonary oedema be managed?

A
  1. Sit patient upright
  2. High flow oxygen if low sats
  3. IV access, and monitor ECG. Treat any arrhythmias
  4. Diamorphine 1.25-5mg IV slowly
  5. Furosemide 40-80mg IV slowly
  6. GTN spray 2 puffs sublingual, or 2x0.3mg tablets sublingual
  7. Necessary examination, investigation, and history
  8. If systolic BP >100mmHg, start nitrate infusion. If systolic BP <100mg, treat as cardiogenic shock and refer to ICU
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12
Q

Why should you avoid supplemental oxygen in those with normal saturations in severe pulmonary oedema?

A

Because it may cause vasoconstriction and reduce cardiac output

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13
Q

What should you do if a person with known COPD has reduced saturations in severe pulmonary oedema?

A

Still give high-flow oxygen, but monitor closely for CO2 retention (check serial ABG if needed), and reduce flow as soon as possible

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14
Q

When should caution be employed when giving diamorphine in severe pulmonary oedema?

A
  • Liver failure
  • COPD
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15
Q

When are larger doses of furosemide required in the treatment of severe pulmonary oedema?

A

Renal failure

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16
Q

What should be done if the patient is worsening after your initial acute management?

A
  1. Further dose of furosemide 40-80mg
  2. Consider CPAP
  3. Increase nitrate infusion if able to do so without dropping systolic BP >100mmHg
  4. Consider alternative diagnoses
17
Q

How does CPAP work in severe pulmonary oedema?

A

It improves ventilation by recruiting more alveoli, driving fluid out of alveolar spaces and into vasculature

18
Q

What alternative diagnoses can be considered if a patient continues to worsen with severe pulmonary oedema?

A
  • Hypertensive heart failure
  • Aortic dissection
  • Pulmonary embolism
  • Pneumonia
19
Q

How should process be monitored in severe pulmonary oedema?

A
  • BP
    Pulse
  • Cyanosis
  • Respiratory rate
  • JVP
  • Urine output
  • ABG
  • Observe on cardiac monitor or telemetry in case of arrhythmias
20
Q

What should be done once a patient with severe pulmonary oedema is stable and improving?

A
  • Daily weights
  • Repeat CXR
  • Modify medications
  • Consider (if patient is suitable) for biventricular pacing or cardiac transplantation
  • Optimise management of AF if present
21
Q

What modifications to medications should be made when a patient with severe pulmonary oedema is stable and improving?

A
  • Change to oral furosemide or bumetanide
  • If on large doses of loop diuretic, consider the addition of a thiazide
  • ACE inhibitor if LVEF <40%. If contraindicated, consider hydralazine and nitrate
  • Consider ß-blocker and spironolactone if LVEF <35%

Medical Emergencies (10 decks)

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