Respiratory (NEW) Flashcards
1
Q
PE evaluation
A
Hx
- Dyspnoea
- Pleuritic chest pain
- DVT risk factors (Well’s = NICE TOPS)
- > neoplasia
- > immobility/surgery
- > calf swollen
- > entire leg swollen
- > tender along veinous drainage
- > oedema unilaterally
- > paralysis/paresis
- > superficial veins prominent
- Occasionally
- > cough
- > haemoptosis
- > syncope/presyncope
Exam
- vitals
- > tachypnoea
- > tachycardia
- > hypoxaemia
- > sometimes febrile
- RV strain
- > elevated JVP
- > parasternal heave
- > prominent P2
- Lungs
- > wheeze
- > decreased breath sounds
- Legs
- > DVT
Haemodynamically unstable
- cardiac arrest
- obstructive shock
- persistent hypotension
ECG
- non specific changes (RV strain)
- ddx’s
FBC -anaemia/thrombocytopaenia ->anticoagulation risk EUC -anticoagulant risk -contrast risk Coags -need INR/PT/aPTT LFTs -anticoagulation risk Coags -INR and aPTT (anti-coagulation) Cardiac biomarkers -troponin/NT-BNP/BNP -use when PE confirmed to risk stratify management bHCG -pregnant female (thrombolysis)
CXR -usually normal ->use for ddx's -PE findings ->hamptoms hump ->westermarks sign CTPA ->intra-luminal filling defect Echo -use ->haemodynamically unstable ->risk stratify management -evidence of RV dysfunction is suggestive -rule out alternative ddx's Lower limb compression ultrasound -evidence of DVT V/Q scan -use when contraindicated to CTPA
2
Q
PE management
A
UNSTABLE
- primary survey
- initial stabilisation
- > high flow O2/consider intubation
- > consider fluid (might exacerbate HF)
- immediate thrombolysis + anticoagulation (UFH)
- follow up investigations
- > Echo first line
STABLE
Lower limb compression ultrasound
- evidence of DVT
- > begin anticoagulation
Pretest probability
- Well’s PE
- > less than 4 = PE unlikely
- > greater than 4 = PE likely
- Geneva
PE likely
- start anticoagulation then confirm with CTPA
- don’t do D dimer
- > can’t rule out PE even if low (FN=5%)
PE unlikely
- PERC rule
- > 0/8 criteria = PE ruled out, consider ddx’s
- > anything higher = D dimer
D-Dimer
- normal <500
- > rule out PE, consider ddx’s
- abnormal >500
- > start anticoagulation then confirm with CTPA
RISK STRATIFY MANAGEMENT
- High risk
- > sPESI >0 with +ive echo/CTPA + biomarkers
- > in patient anticoagulation
- > monitor closely, consider thrombolysis if deterioration
- Intermediate risk
- > sPESI=/>0 with either/both echo/CTPA + biomarkers -ive
- > inpatient anticoagulation
- Low risk
- > sPESI = O with -ive echo/CTPA + biomarkers
- > consider outpatient anticoagulation
ANTICOAGULATION
- active phase
- > LMWH, fondapiranux apixaban, rivaroxaban
- > consider contraindications/renal and liver function
- > continue for 3 months
- at 3 months
- > consider ceasing if provoked
- > continue >3 months if unprovoked
- continued therapy
- > DOAC (apixaban/rivaroxaban preferred)
- > warfarin (overlap therapy with parenteral anticoagulant for 5 days or INR>2 for 24 hrs, whichever is longer)
3
Q
Pneumothorax evaluation and management
A
Hx
- ipsilateral pleuritic chest pain
- dyspnoea
- primary
- > often occurs at rest
- > can pin point time
- secondary
- > hx of COPD
- traumatic
- > trauma
- > procedure
Exam
- decreased chest expansion
- ipsilateral
- > hyperinflation
- > hyper-resonance
- > decreased breath sounds
- evidence of underlying respiratory disease?
Tension
- severe dyspnoea/WOB
- tachycardia
- anxious
- diaphoresis
- cyanosis
- tracheal deviation to contralateral side
- widening of intercostal spaces
- syncope/pre-syncope
CXR -visceral pleural line -no lung markers lateral to line -subcutaenous emphysema -evidence of underlying lung disease Consider -CT chest ->mutlitrauma/occult/secondary
Tension management
- immediate needle decompression
- > 2/3rd interspace, midclavicular line
- do not delay for investigations
- chest tube required for all
Primary/secondary/traumatic management
- high flow O2
- > increase rate of spontaneous resolution
- consider need for hospitalisation
- > primary often discharged after several hrs
- > older/secondary/traumatic = chest tube + inpatient
- expectant management if small and stable
- needle aspiration if large
- consider chest tube
- > seldinger technique in triangle of safety
- > attach to one way valve
- > consider suction if persistent air leak
British thoracic society algorithm
