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4th Year ACC > Breathlessness > Flashcards

Breathlessness Flashcards

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1
Q

Cardiac signs of a PE

A

Low BP

High HR

Gallop rhythm

High JVP

RV heave

Cyanosis

AF

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2
Q

Resp sx/signs of a PE

A

Pleural rub and pleuritic pain

Tachypnoea

Cyanosis

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3
Q

What are the scoring tests and algorithm for PE

A

Well’s score:

<4 do d-dimer- negative can rule out, positive do CTPA

> 4 straight to CTPA (or if a delay treat with LMWH)

Low risk- PERC score to rule out

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4
Q

Further investigations in PE

A

CXR

ABG

U&E, FBC, clotting

ECG

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5
Q

What can you use if CTPA unavailable for PE?

A

V/Q scan

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6
Q

What can you use the if susp PE patient is well and the CXR is normal

A

V/Q scan

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7
Q

Management of PE

A

Morphine 5-10mg IV

LMWH or fondaparinux (IV)

Thrombolysis (e.g. alteplase) if haemodynamically stable,
if they are not then consider vasopressors

Anticoags for long term- DOAC or warfarin

Consider the cause

O2 and fluids if needed

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8
Q

If hypotensive/haemodynamically unstable patient with PE who do you need for input?

A

ICU

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9
Q

How do you switch from the LMWH to the longer term anticoag for PE?

A

If DOAC, swap. If warfarin, do both and stop the LMWH when the INR is <2

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10
Q

What causes could there be of PE?

A

DVT, malignancy, thrombophilia, polycythaemia, OCP, pregnancy, immobility.

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11
Q

How long does someone with a PE need to remain on their anticoagulant?

A

Depends:

Provoked PE: 3m then reassess

Unprovoked PE: >3 months

Malignany: 6m or until cancer gone

Pregnancy: until end of pregnancy.

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12
Q

Negative PERC score change of PE?

A

2%

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13
Q

What might the CXR show in PE?

A

decreased vascular markings, wedge shaped infarct

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14
Q

What might the ECG show in PE?

A

often normal or sinus tachycardia

May have:

RBBB

AF

RA deviation

S1Q3T3

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15
Q

What is S1Q3T3?

A

S wave in lead 1 is deep

Q wave present in lead 3

T wave inverted in lead 3

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16
Q

4 causes pulmonary oedema

A

Cardiac

ARDS

Fluid overload

Neurogenic

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17
Q

Symptoms pulmonary oedema

A

Dyspnoea, orthopnoea, pink frothy sputum

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18
Q

Examination findings in pulmonary oedema

A

Raised JVP

Fine crackles

Gallop rhythm

Wheeze

Usually sitting up and leaning forward, distressed, pale, sweaty

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19
Q

Investigations to get in susp pulmonary oedema

A

CXR

ECG

U&E, troponin, ABG, BNP

Possibly an echo

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20
Q

What does CXR pulmonary oedema show?

A

Alveolar oedema

B-lines (kerly)

Cardiomegaly

Diversion of upper lobes (blood vessel dilation)

Effusions bilaterally

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21
Q

What are you looking for in pulmonary oedema ecg?

A

MI

dysrhthmia

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22
Q

Management of pulmonary oedema

A

Sit up right

High flow O2

IV access and monitor ECG, treat arrhythmias

Diamorphine 1.25-5mg IV slowly

Furosemide 40-80mg IV slowly

GTN 2 puffs (unless sys BP <90), if systolic BP >/= 100 start nitrate infusion

Observe on cardiac monitor/telemetry

Daily weighing and repeat CXR

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23
Q

What would you do if pulmonary oedema is worsening further following initial management?

A

A further 40-80mg furosemide.

Consider CPAP

Increase nitrate if able to without dropping BP

Consider alt diagnosis

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24
Q

If someone with pulmonary oedema has systolic BP <100 how do you treat it?

A

Treat as cardiogenic shock and send to ICU

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25
How much do you want the weight to decrease by each day in pulmonary oedema?
0.5kg/day
26
60-75% pneumonias are caused by ___?
Strep pneumoniae
27
Staph aureus is a more common cause of pneumonia in which group?
ICU pts
28
Four other common pathogen causes of pneumonia
Viruses Haemophilus influenzae, m. pneumoniae, legionella, chlamydia psittaci
29
What pathogen is likely to cause pneumonia in HAP, immunocompromised and COPD
Pseudomonas
30
15% pneumonia is caused by _____
viruses e.g. influenza
31
What four signs might you notice in pneumonia
Dull percussion note Increased tactile vocal f/r Bronchial breathing Pleural rub
32
What investigations do you do initially for pneumonia
CURB 65 score CXR SpO2 ± ABG FBC, U&E, LFT, CRP Consider viral throat swab and mycoplasma PCR/serology
33
What does each bit of CURB 65 stand for?
confusion (AMTS <8) Urea (>7mmol/L) Resp rate (30+/min) BP (<90/60) >65yo
34
How do you interpret the CURB score
0-1 home Rx >2 hospital 3+ severe, to ICU
35
If CURB is >2 what further investigations do you do?
Blood cultures, IV antibiotics (PO if <2), urine pneumococcal and legionella urine antigens, sputum cultures
36
Management of pneumonia
ABC- Oxygen, fluids if needed Antibiotics - depends on CURB and guidelines Analgesia If hypoxic on O2- ventilator/CPAP
37
What antibiotics are generally given
CURB 0-1- amoxicillin/clarithromycin/doxycycline 2- amox and clarithro or doxy 3- co-amox or cephalosporin AND clarithro (all IV)
38
Hospital acquired pneumonia is more likely to be caused by which three types of organism?
Gram -ve bacilli Pseudomonas Anaerobes
39
Antibiotics generally for HAP?
Aminoglycoside + antipseudomonal penicillin or 3rd gen ceph (all IV)
40
Is there a diagnostic test for asthma?
No, tests just influence probability
41
What is classed as moderate acute asthma?
PEF >50-75% best/predicted
42
What makes acute asthma acute severe?
Any one of: 1. PEF 33-50% best/predicted 2. Resp rate >/=25 3. HR >/=110 4. Unable to complete sentences in 1 breath
43
What makes asthma life-threatening?
Severe + any one of: 1. PEF <33% best/predicted 2. SpO2 <92% 3. PaO2 <8kPa 4. Normal PaCO2 (4.6-6) 5. Silent chest 6. Cyanosis 7. Poor respiratory effort 8. Arrythmia 9. Exhaustion 10. Altered conscious level 11. Hypotension
44
What makes acute asthma 'near fatal'?
PaCO2 raised and/or requiring mechanical ventilation with raised inflation pressures
45
Which asthma patients require ABG?
SpO2 <92% or other features of life-threatening Or not responding when should be or deteroirating
46
Do you CXR acute asthma?
If life threatening, not responding or require ventilation
47
Which asthma patients should be admitted
- Any feature of life threatening or near-fatal - Any feature of acute severe persisting after initial treatment If their PEF is >75% best/predicted after 1 hour of treatment they may be discharged from the ED (unless other reasons why admission might be appropriate).
48
What is the mnemonic for asthma management?
OSHITME
49
What O2 sats should you aim for in asthma
94-98%
50
if you don't have a sats probe should you still give oxygen in acute asthma?
Yes don't delay, but commence monitoring as soon as available
51
What is the first line treatment for acute asthma?
B2 agonist (salbutamol) ASAP
52
What route should the salbutamol be given by and what dose for acute asthma?
In moderate and acute severe: - inhaler. - 2-10 puffs every 10-20 mins or PRN (each puff is 100 micrograms) In life threatening, or in refractory: - nebulised (O2 driven) - 5mg every 20-30 minutes or PRN
53
Which acute asthma patients should receive steroids? Which one, dose etc?
All of them Prednisolone PO 40–50 mg daily for at least 5 days or until recovery.
54
What is an alternative steroid for acute asthma if can't swallow?
Hydrocort IV
55
When should you add ipratropium bromide to Rx in acute asthma?
-Acute severe or life threatening OR -poor response to initial salbutamol
56
Dose of Ipratropium bromide in acute asthma?
0.5mg 4-6 hourly nebulised (add to the nebuliser as well as salbutamol)
57
Is nebulised mgso4 recommended in acute asthma?
No
58
When would you consider giving magnesium in acute asthma?
In acute severe that has not had good initial response to salbutamol Need consultation with senior
59
Magnesium sulphate route and dose in acute asthma?
IV infusion over 20 mins 1.2-2g
60
What is the E in OSHITME?
Escalate
61
Which acute asthma patients should be referred to intensive care?
- require ventilatory support - acute severe or life-threatening that is failing to respond (evidenced by deteriorating PEF, persisting or worsening hypoxia, hypercapnia, ABG analysis showing decreasing pH, exhaustion, drowsy, confused, altered consciousness poor respiratory effort or respiratory arrest.)
62
How should asthma attack be followed up?
Inform GP within 24hr Near fatal- specialist supervision indefinitely Severe- f/u by respiratory for at least 1y.
63
What investigations would you do in someone who presented with acute asthma?
PEFR SpO2 ABG- IF spo2 <92% or life-threatening Resp examination
64
What is a mnemonic to remember things to ask in breathlessness history?
ONE RESP Onset Nature Exercise tolerance Relieving Exacerbating Sleep Pillows
65
Investigations to do for infective exacerbation COPD
ABG CXR (r/o pneumothorax and pneumonia) FBC, U&E, CRP ECG Temperature Sputum microscopy and culture if purulent Blood culture if pyrexial
66
What should you ask the patient early in an acute exacerbation COPD
Wishes on ICU and ventilation
67
Basic management steps in acute exacerbation COPD
Oxygen (if SpO2 <88% or PaO2 <7kpa) Bronchodilators Steroids Antibiotics if indicated Physio
68
Which management can you start immediately before needing to do ABGs, CXR
Bronchodilators
69
How do you give O2 therapy in acute exacerbation COPD
Start at 24-28% FiO2 and aim for 88-92% SpO2 Get an immediate ABG and then titrate the FiO2 with serial ABGs to find the minimum FiO2 that will give clinical improvement, without resulting in hypercapnia or acidosis. Aim for PaO2 >8kpa with a rise in PaCO2 <1.5kpa
70
What bronchodilator should you give in acute exacerbation COPD?
Nebulised salbutamol 5mg/4hr Consider adding ipratropium 0.5mg/6h
71
Should the nebuliser be O2 driven in acute exacerbation COPD?
Yes unless they are known to be a hypercapnoeic, acidotic COPD patient in which case you use compressed air to drive the neb, and supplement with nasal prong O2 1-4L
72
What steroids do you give in acute exacerbation COPD?
Oral prednisolone 30mg PO stat (and then OD for 7-14 days) Or IV hydrocortisone 100mg
73
When do you give antibiotics in acute exacerbation COPD and what?
If evidence of infection E.g. amoxicillin 500mg TDS PO
74
What is physio for in COPD?
Aid expectoration
75
What could you do if no response to initial treatment in acute exacerbation COPD?
IV aminophylline
76
What would you do if IV aminophylline didn't work in an acute exacerbation COPD?
non invasive ventilation (NIPPV) if no response and: RR >30 pH <7.35 PaCO2 raised Or becoming increasingly exhausted/agitated/confused
77
Contraindications to NIPPV in acute exacerbation COPD?
apoea pneumothorax severe agitation inability to tolerate or fit the face mask
78
What could you do in acute exacerbation COPD if NIPVV didn't work?
ONLY IF APPROPRIATE FOR THE PATIENT (level of function etc) Intubation and ventilation (pH <7.26 and PaCO2 rising)
79
If can't do peak flow how do you estimate?
Height and gender Or ask them what is normal
80
What is a side effect of prednisolone that might make you want to give hydrocort IV instead?
Prednisolone makes you want to vomit
81
How long does it take for steroids to work in asthma?
6-12hr
82
Do IV steroids work quicker than PO in asthma?
No
83
Do you have to check magnesium levels before giving it in asthma?
No
84
When do you give bipap in copd?
resp acidosis tried medical therapy for an hour
85
What do you need to do before bipap in copd?
CXR to check for pneumothorax
86
Infective resp symptoms, IVDU and drop sats on exertion suggests what pathogen of pneumonia?
Pneumocystis jiroveci
87
Pneumonia pathogen in long term ventilator
Staph aureus
88
Coming back from week in Spain pneumonia pathogen?
Legionella
89
pneumonia pathogen in alcoholic and diabetic
Klebsiella

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