Week 1 - Acute Medical Presentations 1 Flashcards
A 60 year old man is reviewed on the acute medical unit with acute central chest pain radiating to his left arm. On examination he is grey and sweaty but is apyrexial. His pulse of 60 beats per minute, his BP is 140/80 mmHg and his transcutaneous O2 saturation is 96% on room air. He has a loud systolic murmur at the apex of the heart. His chest is clear.
Which is the most important immediate investigation?
Chest X-ray
D-dimer
Electrocardiogram
Full blood count
Troponin T
Correct: Electrocardiogram
Whilst there may be a case for doing any or all of these investigations (and indeed most are done as part of patient triage before formal medical assessment) the most urgent is an ECG. His presentation suggests and acute MI and an ECG would identify an ST-elevation MI which requires emergency management.
A 45 year old woman is reviewed on the acute medical unit with chest pain. She describes a burning central discomfort worse after eating particularly when lying flat and when bending forwards.
Which is the most likely cause of her pain?
Aortic dissection
Gastro-oesophageal reflux
Myocardial ischaemia
Pericarditis
Pulmonary embolism
Correct: Gastro-oesophageal reflux
Chest pain assessment based solely on the history can be difficult but in a younger patient with pain after meals and increased by postural changes that facilitate the passage of gastric fluids, gastro-oesophageal reflux is the most likely cause.
A Year 3 medical student is clerking a patient who collapses to the floor without warning.
Which is the best way to recognise a cardiac arrest?
Absence of carotid pulse
Absence of heart sounds
Absence of movement in response to painful stimuli
Absence of respiration
Asystole or ventricular fibrillation on ECG
Correct: Absence of respiration
Whilst any of these may cause be seen in a cardiac arrest, the best way to recognise this condition is by the absence of respiration.
The medical student calls for help and starts cardiopulmonary resuscitation (chest compressions).
Which is the most appropriate site, rate and depth for compressions?
Central sternum, 8-10 cm in depth at 80/minute
Lower sternum, 5-6 cm in depth at 100/minute
Lower sternum, 8-10 cm in depth at 100/minute
Upper sternum, 2-4 cm in depth at 80/minute
Upper sternum, 5-6 cm in depth at 60/minute
Correct: Lower sternum, 5-6 cm in depth at 100/minute
The recommendations for CPR are: on a firm surface, lower sternum, 5-6cm in depth at 100/minute allowing full recoil between compressions
A 32 year old woman is brought in to A&E by by the paramedic crew having been resuscitated following an out-of-hospital cardiac arrest. She was previously well. The initial mode of her arrest was pulseless electrical activity (PEA). On arrival she is in shock with a BP of 50/30 mmHg and has an elevated JVP. A bedside echocardiogram shows a dilated right heart.
Which of the 4 ‘Hs’ and 4 ‘Ts’ is the most likely cause for her PEA arrest?
Hypothermia
Hypovolaemia
Thrombus
Tamponade
Tension pneumothorax
Correct: Thrombus
It always pays to keep an open mind in this setting but a PEA arrest in previously well young woman with high JVP and right heart dilation on echo is very suggestive of pulmonary embolism (ie Thrombus). Unless she has been pulled out of cold water, hypothermia is not likely at this age and her high JVP excludes hypovolaemia. Her echo rules out tamponade. A tension pneumothorax could present in this way but PE is much more likely.
Which of the following is associated with a high likelihood for PE?
A modified Wells score of 2
d-dimer level < 0.2
pCO2 on air of 6.5kpA
Normal pulse rate
Knee replacement surgery 2 weeks ago
Correct: Knee replacement surgery 2 weeks ago
A modified Wells score of 2 or less indicates a low risk of PE. A normal d-dimer level (< 0.2) can be helpful in excluding a PE. You would expect hypoxia and tachycardia in a PE. Prolonged immobilisation increases risk of VTE.
What is the most common ECG finding in a patient presenting with a PE?
Atrial fibrillation
Sinus tachycardia
S1 Q3 T3
Pulseless electrical activity (PEA)
Saddle shaped ST elevation
Correct: Sinus tachycardia
Sinus tachycardia is the most common ECG finding in patients presenting with PE. S1Q3T3 is typical for PE but a much rarer finding resulting from right heart strain. Other ECG changes in right heart strain are ST depression and T wave inversion in V1-V3 and right bundle branch block. AF can also be present and in a cardiac arrest secondary to massive PE, the ECG rhythm could be PEA. Saddle shaped ST elevation is typical for pericarditis.
Which investigation would have highest diagnostic yield in confirming a suspected PE
US doppler
CTPA
d-dimer and ABG
Troponin and d-dimer
Echocardiogram
Correct: CTPA
CTPA is the gold standard test as per current guidelines.
US Doppler of lower limbs are used for diagnosing DVT but can be helpful if a CTPA is contraindicated. A d-dimer and ABG are useful investigations to support suspicion for PE. Troponin levels can be elevated in massive PE but troponin is not a highly specific test and levels can be raised in many other conditions. Right heart strain can also be identified on echocardiogram but only increases the probability of a PE and does not confirm the diagnosis. An echocardiogram may show the intraventricular septum bulging into LV cavity, increased RA and RV pressures and dilatation of IVC.
Which of the following is NOT a risk factor for thromboembolic disease (TED)?
Recent surgery
8-hour car journey
Malignancy
OCP
FH haemophilia
Correct: FH haemophilia
Remember Virchow’s triad of stasis, hypercoagulability and endothelial damage. Prolonged immobilisation following surgery and from a long-haul flight increases the risk of VTE. Malignancy and OCP are recognised risk factors for PE. The Wells criteria for PE incorporate risk factors for VTE to objectify probability of PE. Haemophilia is an X linked inherited condition that increases bleeding tendencies.
A 56 year old is admitted with a community acquired pneumonia and suddenly becomes unwell with acute breathlessness, wheeze and dizziness after a dose of intravenous Amoxicillin. She informs you she has a penicillin allergy. Her BP is 80/60 and oxygen saturations on air dropped to 88%. What is the management of this patient?
28% oxygen through venturi mask, 1:10,000 iv adrenaline, iv fluids, iv anti-histamine
28% oxygen through venturi mask, 1:1000 im adrenaline, iv fluids, βs agonist nebuliser
High flow oxygen, 1:10,000 iv adrenaline, iv fluids, iv anti-histamine
High flow oxygen, 1:1000 im adrenaline, iv fluids, β2 agonist nebuliser
High flow oxygen, 1:10,000 iv adrenaline, iv fluids, β2 agonist nebuliser
Correct: High flow oxygen, 1:1000 im adrenaline, iv fluids, β2 agonist nebuliser
This patient has anaphylaxis, a life-threatening medical emergency. The first and most important treatment for anaphylaxis is adrenaline and should be given immediately. IM administration of adrenaline is preferred over iv as it is usually a faster route of administration and safer with lower risks of cardiovascular complications such as ventricular arrhythmias and severe hypertension. For anaphylaxis, the dose of adrenaline is a 1/10th of the dose of iv adrenaline used in cardiac arrest. 1:10,000 intravenous adrenaline is for cardiac arrest scenarios. High flow oxygen is needed to improve tissue oxygenation for patients in shock and with bronchospasm. Additional therapy includes β2 agonists for bronchodilation. Although antihistamines are sometimes administered in anaphylaxis, they do not relieve airways obstruction or shock.
How can the following areas be sources of acute chest pain?
- Heart
- Lungs
- Oesophagus
- Aorta
- Chest wall / Spine
- Intra-abdominal pathology
What type of pain is
- Worse on inspiration
- Worse when lying flat
Inspiration = pleuritic pain
Flat = pericarditic pain
What is Virchow’s triad?
Factors that contribute to thrombosis:
Stasis
Prothrombotic state
Vascular injury
What can the following be indicative of?
- High Pulse
- Low Pulse
- High BP
- Low BP
- Dec RR and O2 Sat
- High Temp
- Raised JVP
- Bronchial breathing
- Crackles
- Pleural rub
Heart sounds:
- AR
- AS
- Rub
- High Pulse = ?PE
- Low Pulse = myocardial ischaemia
- High BP = aortic dissection
- Low BP = ?MI, PE or sepsis
- Dec RR and O2 Sat = PE, lung path, MI complications
- High Temp = infection
- Raised JVP = MI, PE
- Bronchial breathing = pneumonia
- Crackles = infection, fluid
- Pleural rub = pleurisy
Heart sounds:
- AR = aortic dissection
- AS = exertional angina
- Rub = pericarditis
What blood works can be done for
- suspected MI
- possible PE
MI - troponin
D-Dimer - PE
What imaging can be done for
- possible PE?
- possible dissection
PE = CTPA
Dissection = Aortogram
How does aortic dissection present?
What are the clinical signs of aortic dissection?
AR signs - AR murmur, collapsing pulse, low diastolic BP
Missing pulses, differential arm BPs
Pericardial effusion / tamponade - tachycardia, high JVP, low BP
Neurological - TIA, stroke
What are the risk factors for aortic dissection?
HT (if uncontrolled)
Collagenopathies (Marfan syndrome)
What is the investigation of choice for aortic dissection?
CT Aortogram
What is the difference between Type A and B aortic dissections?
Type A - ascending aorta
Type B - descending aorta involvement
Type A - more likely to cause AR and pericardial effusion
Type A - need urgent surgery
Type B - can try medical Tx / stenting
How is aortic dissection treated?
Analgesia
Control BP - IV Labetalol, invasive monitoring
Avoid hypovolaemia - IV fluids through central line
Monitor urine output - make sure renal arteries are not affected
Surgery or medical Tx
When do we assume cardiac arrest?
Absence of respiration
Slow, laboured “agonal” respiration
Which rhythms are shockable in cardiac arrest?
Which rhythms are not shockable
VF
VT
Not-shockable = Asystole, PEA
What rhythms are seen here?
What rhythms are seen here?
What rhythms are seen here?
What is PEA?
Pulseless electrical activity (PEA) is a condition where your heart stops because the electrical activity in your heart is too weak to make your heart beat.
What are the causes of PEA arrest?
4Hs 4Ts
What are the steps of the ALS algorithm for MI
Shocks - 150/200 and inc to max
IV Access
Adrenaline every 3-5min
Amiodarone - after 3 shocks
Identify reversible causes
What are signs of ROSC?
Breathing
Coughing
Movement
Palpable pulse
What medication is given to control BP in an emergency?
IV Labetalol if too high
Noradrenaline / adrenaline if too low
What is an example of acute on chronic respiratory failure?
Can have chronic respiratory failure such as COPD and then catch pneumonia on top = acute on chronic
Which NM diseases are linked to respiratory failure?
Guillain Barre
Myasthenia gravis
What are possible differentials for pleuritic chest pain?
What type of pain is pleuritic chest pain?
Sharp stabbing pain that is worse on inspiration
What is the definition of a pneumothorax?
Air in the pleural space
What is the difference between primary and secondary pneumothorax?
A primary pneumothorax is considered the one that occurs without an apparent cause and in the absence of significant lung disease. On the other hand secondary pneumothorax occurs in the presence of existing lung pathology.
What is a tension pneumothorax?
Air leaking out of the lungs into the pleural space that cannot escape - causes mediastinal shift and can result in a cardiac arrest.
How is pneumothorax categorised by size?
Small <2cm from chest wall
Large >2cm from chest wall
What are the RF for primary pneumothorax?
Asthma
Smoking,
Tall / thin
Collagen vascular diseases (Marfan syndrome)
If prior pneumothorax - risk of recurrence is 54% in first 4 years
Which is more serious - primary or secondary pneumothorax?
Secondary - Ps are normally older with more comorbidities
How does pneumothorax usually present?
What are the signs of pneumothorax?
Always compare the two sides - best way to tell if there is a difference
How can you tell if there is a tension pneumothorax?
Silent-chest & hyper-resonant + mediastinal shift.
Collapse
Cardiac arrest
What investigations should be done for pneumothorax?
Posterior-anterior CXR
HRCT Thorax
ABGs
How is primary pneumothorax managed?
Can discharges if relatively asymptomatic, not hypoxic and under 50. MUST follow up.
If symptomatic do not discharge.
How is secondary pneumothorax managed?
What is pleurodesis?
Pleurodesis is a procedure that sticks your lung to your chest wall. This procedure removes the space between your lung and your chest wall (pleural space) so that fluid or air no longer builds up between the layers.
What is a pleurectomy?
A pleurectomy is a surgical procedure to remove part or all of the pleura, a membrane that lines the lungs and chest cavity. The procedure treats empyema — an infection of the pleural cavity — and other lung conditions.
How do we treat tension pneumothorax?
Clinical diagnosis
Immediate aspiration and intercostal tube drainage
Insert wide bore needle in the 2nd intercostal space in the anterior axillary line
What is an acute PE?
What does the severity of the PE depend upon?
Which pulmonary artery is blocked.
Saddle embolus = central = life threatening
Segmental = severe
Sub-segmental = unlikely life-threatening - often found incidentally
How does PE present?
Acute breathlessness
Pleuritic chest pain
- PE
Cough, haemoptysis, hypotension, collapse, cardiac arrest - ? PE or Tension Pneumo
What are the signs of PE?
HR >100
RR > 24
Raised JVP, right ventricular heave, loud P2
Hypoxic in 60% cases
Which score calculates the risk of PE?
Modified Wells Score
What investigations are done for suspected PE?
CXR
ECG
ABGs
D-Dimer
CTPA
Echo
Doppler US
If any 2 of D-Dimer, ABG and RR are normal - what does this mean with the likelihood of PE?
That PE is very unlikely
How does an ECG show PE?
Sinus tachycardia
RBBB
R axis deviation
S1 Q3 T3
A large S wave in lead I, a Q wave in lead III and an inverted T wave in lead III together indicate acute right heart strain.
How is acute PE managed?
ABCs
O2 and analgesia
DOAC
How is the severity of PE scored?
PESI score
Pulmonary Embolus Severity Index
Acute breathlessness from upper airway oedema, bronchospasm and obstruction with possible swelling of throat / tongue / lips, hoarse voice and stridor indicates what?
Anaphylaxis
Why do Ps with anaphylaxis suddenly collapse sometimes?
Due to hypovolaemia due to low BP - causes CVS collapse
How is anaphylaxis managed?
ABCs
O2
Adrenaline - 1 in 1000 IM adults
IV fluids (NaCl or Hartmann’s) - 0.5L to 1L
Nebulised β 2 agonist
What do you to beware of with anaphylaxis?
Biphasic reaction - second wave can occur after 12 hours
What blood test can be done in anaphylaxis?
Blood test for Mast Cell Tryptase
What do the following indicate?
1. Pericardial rub
2. Pleural rub
3. Elevated JVP
4. Cardiac murmur
5. Absent/weak pulse or differential BP between the 2 arms
- Pericardial rub (pericarditis)
- Pleural rub (pleurisy – pneumonia or PE)
- Elevated JVP (likely circulatory cause, eg MI or PE)
- Cardiac murmur (eg aortic regurgitation in aortic dissection)
- Absent/weak pulse or differential BP between the 2 arms (aortic dissection)
What can cause lateral T wave inversion?
LVH
Digoxin
How does digoxin affect ECG readings?
Regular intake of digoxin results in decreased QT interval, prolongation of the PR interval, and T wave inversion or flattening
What abnormalities are seen on this CXR?
Widened upper mediastinum (even allowing for AP projection)
2. Left basal shadowing (?effusion, ?consolidation, ?elevated left hemidiaphragm)
NB subtle arrows indicating these.
What investigations should be done following cardiac arrest?
All patients should have ECG, ABG and FBC/U&E following cardiac arrest resuscitation. Following a VT arrest an echocardiogram should also be done (?LV function). CT scanning for PE, an acute cerebral event of intra-abdominal pathology may be considered but are not urgent unless other features suggest those pathologies.
What are the following types of pain indicative of?
- a retrosternal heavy or gripping sensation with radiation to left arm or neck, that is provoked by exertion and eased with rest or nitrates
- similar pain as above but at rest
- severe tearing chest pain radiating through to the back
- sharp central chest pain that is worse with movement or respiration but relieved by sitting forward
- sharp, stabbing, left submammary pain associated with anxiety
- a retrosternal heavy or gripping sensation with radiation to left arm or neck, that is provoked by exertion and eased with rest or nitrates = Angina
- similar pain as above but at rest = Acute Coronary Syndrome
- severe tearing chest pain radiating through to the back = Aortic Dissection
- sharp central chest pain that is worse with movement or respiration but relieved by sitting forward = Pericarditis
- sharp, stabbing, left submammary pain associated with anxiety = Da Costa’s syndrome
What is Cheyne-Stoke respiration and what is it a sign of?
Alternating episodes of apnoea and hyperventilation - associated with severe heart failure
What can cause disregulated breathing with cardiac issues?
Poor cardiac output affects the respiratory centre in the brain => central sleep apnoea syndrome
What are ectopic beats felt like by the patient?
A pause followed by a forceful beat - this is because the next beat is more forceful as the heart has had a longer diastolic period and is therefore full of more blood requiring a stronger contraction
What are paroxysmal tachycardias felt like?
Sudden racing heart beats
What is the severity of cardiac symptoms graded by?
The New York Heart Association Grading of Cardiac Status
What causes of vascular syncope are there?
Vasovagal - peripheral vasodilation = pooling of blood and reduced preload. Heart contracts vigorously - triggers stretch receptors in left ventricle - tiggers CNS reflex to reduce ventricular stretch by vasodilation and bradycardia - this can cause drop in BP = syncope.
Postural hypotension
Postprandial hypotension
Micturition syncope
Carotid sinus syncope - exaggerated response to carotid sinus stimulation
What are the causes of obstructive syncope?
AS
Hypertrophic cardiomyopathy
Pulmonary stenosis
PE / Pul HT
Atrial myxoma / thrombus
Defective prosthetic valve
All lead to syncope due to restriction of BF from heart into circulation
Which cardiac medication can cause fatigue as a SE?
β blockers
Why does heart failure cause peripheral oedema?
Salt and water are retained - this is due to low BP from the HF which activates RAAS - causing retention of Na and water - leading to pitting oedema.
