Emergencies Flashcards
How are pneumothoraces categorised?
Primary = YOUNG, Spont due to rupture of sub-pleural bleb Secondary = >55YO SMOKERS, Lung pathology
What are the risk factors for a pneumothorax?
Asthma/COPD Infection: TB, pneumonia, lung abscess CT disorder: Marfan's, Ehlers Danlos Trauma/iatrogenic Lung Ca Lung disease: CF, fibrosis, sarcoid
What are the common iatrogenic causes of a pneumothorax?
Pleural aspiration Bronchial biopsy Liver biopsy \+ve pressure ventilation Subclavian CVP line
How does a pneumothorax present?
Asymptomatic Acute progressive dyspnoea Pleuritic chest pain Laboured breathing Tracheal deviation ↓Ipsilateral: Expansion, tactile remits, breath sounds, air entry ↑Ipsilateral: Resonance Pleural rub
How is a pneumothorax investigated?
Determine 1o or 2o
CXR
Bloods: FBC, U&E, Clotting, ABG
ECG: Tachy
Was is classed as a small and a large pneumothorax?
Small = <2cm Large = >2cm
How does a tension pneumothorax occur?
One way valve Continually expanding pneumothorax into pleural space No escape when expiring Mediastinal shift to C/L side Compresses great veins Haemodynamic compromise Cardio-respiratory arrest
How is a tension pneumothorax treated?
O2 15L/min NRB
Needle decompression: 2nd ICS midclav OR triangle of safety
Chest drain in triangle of safety
What are the borders of the triangle of safety?
Ant: Lat border of pec major
Post: Lat border of Lat Dorsi
Inf: 5th rib
How is a primary pneumothorax managed?
> 2cm/SOB: Aspirate 16-18G cannula- aspirate <2.5L. If successful consider discharge + review in 2-4w
NOT successful: Chest drain + admit
<2cm/No SOB: Consider discharge & review in 2-4w
How is a secondary pneumothorax managed?
> 2cm/SOB: Chest drain & admit
1-2cm: Aspirate 16-18G cannula- aspirate <2.5L. If successful (<1cm) = ADMIT (observe for 24hrs) If NOT successful Chest drain & admit
<1cm: ADMIT (observe for 24hrs)
What is the mechanism behind a PE?
Venous thrombi (DVT) dislodges (emboli)
Reaches pulmonary circulation
Unable to fit through & blocks blood flow to lungs
What are the risk factors for a DVT?
Pro-Coag states: COCP, malignancy, nephrotic syndrome
Venous stasis: Immobile, Rx surgery, Pelvic mass, Obesity, Pregnancy/childbirth, Long travel
Miscellaneous: Prev or Fhx of PE/DVT,
Apart from a DVT what other things can cause a PE?
RV thrombus: Post-MI Septic emboli: Tricuspid endocarditis Fat emboli: Long bone # Air emboli: Venous lines, diving Amniotic fluid emboli: Pregnancy
How does a PE present?
Pleuritic chest pain + Dyspnoea = SUDDEN onset Haemoptysis Tachycardia Tachypnoea ↓O2 sats ↑JVP DVT LARGE: Cyanosis, HypoT
How is a PE investigated?
CTPA = DIAGNOSTIC +ve = Heparinise VQ scan ABG: ↓PaO2, ↓PaCO2 = RESP ALKALOSIS ECG CXR: Rarely signs Bloods: APTT, Troponin, D-dimer WELLS Score: >4 = likely Pulm angio = last line
What signs may be seen on ECG to suggest PE?
Sinus Tachy R axis deviation RBBB T wave inversion S1 Q3 T3
What does the Wells Score tell you in ?PE ?
Whether a PE is likely or not:
>4 = Likely → CTPA
<4 = Unlikely → D-Dimer= rule out
What does a D-Dimer tell you in ?PE ?
+ve = may be PE → CTPA/VQ scan
-ve + Wells Score <4 = PE unlikely
Which patients would get a VQ scan over a CTPA?
Allergic to contrast
CKD
How is a haemodynamically stable pt with a PE treated?
O2: 15L/min NRB
LMWH: Tinz 175u/kg OR Fondaparinux OR UFH for 5d
Cardiac monitoring
NSAIDS
What should all people with an ‘unprovoked’ PE get?
Cancer screen!
CT
How is a haemodynamically unstable pt with a PE treated?
500ml NaCl if hypoT
1) Thrombolysis: Alteplase OR Streptokinase
2) Embolectomy if thrombolysis CI
3) IVC filter
How is a patient with a PE anticoagulated?
Confirmed PE = Warfarin OR NOAC Overlap LMWH w/Warfarin or NOAC until INR 2-4 Stop LMWH Provoked = Warfarin for 3m Unprovoked = Warfarin for 6m Continuing RFs (malignancy) = Lifelong
