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ACC > Emergency medicine: chest pain and breathlessness > Flashcards

Emergency medicine: chest pain and breathlessness Flashcards

1
Q

What is the acute management of a patient with an infective COPD exacerbation?

A

ABCDE
A
1. Maintain airway

B

  1. Monitor RR, %O2 Sats
  2. Oxygen 15 L/min via NRBM or use Venturi (aim for 88-92% saturation)
  3. 5mg Salbutamol nebuliser
  4. add 500mcg of Ipratropium bromide (repeat 15-20 mins if no improvement

C

  1. Gain IV access
  2. ABG
    - if hypoxic increase FiO2,
    - if hypercapnic >6kpa and acidotic < 7.3 start BIPAP and refer to ICU
  3. Abx - Amoxicillin, erythromycin, doxycyline
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2
Q

When would you start BIPAP in a COPD patient?

A

pH < 7.3

PaCO2 > 6

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3
Q

What is the treatment for CAP?

A

Amoxicillin (1st line)

Doxycycline and Erythromycin

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4
Q

What is the treatment for HAP?

A

Cefuroxime or other cephalosporin

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5
Q

How does atypical pneumonia present? give an example of a causative organism?

A

Mycoplasma pneumonia

Fever 
Headache 
Upper abdominal pain 
Dry cough (as oppose to productive in typical) 
Vomiting 
Miserable and flushed
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6
Q

Define HAP?

A

pneumonia that manifests > 48hrs post-hospital admission

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7
Q

What is the screening tool for predicting mortality in pneumonia? How are the scores categorised?

A

CURB65

  1. Confusion
  2. Urea ≥ 7 mmol/L
  3. RR ≥ 30
  4. BP < 90 syst, <60 diast
0-1 = treat from home 
2 = admission 
3 = high risk of death
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8
Q

What is the investigative pathway of PE?

A

Suspected PE based on clinical presentation?

  1. Two level Well’s score
    - > 4 PE likely = CTPA
    - < 4 PE unlikely = D-Dimer
  2. D-Dimer
    - +ve = CTPA
    - -ve unlikely PE = V/Q if you want
  3. CTPA
    - +ve = treatment
    - -ve unlikely
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9
Q

What is the acute treatment of confirmed PE?

A

ABCDE

  1. Maintain airway
  2. Oxygen 15L/min via NRBM - aim for 94%
  3. IV Access and cardiac monitor (r/v every 15 mins)
  4. LMWH or Fondaparinux or UFH (if sev renal imp) for 5 d
  5. PO NSAIDs for pain relief (avoid opiate due to respiratory depression)
  6. Anticoagulate - warfarin (overlap until INR 2-3) or NOAC
  7. Cancer screen for all unprovoked incidences

If Haemo-dynamically unstable

  1. Thrombolysis (alteplase or streptokinase)
  2. Embelectomy if thrombolysis is CI
  3. Fluids IV 500ml Hartmann’s
  4. IVC filter
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10
Q

What are the investigations ordered for HF?

A
  1. BNP
    - if > 400 = Echo within 2 weeks
    - if 100-400 = Echo within 6 weeks
    - if < 100 = unlikely HF
  2. ECG
    - L/RAD, L/R ventricular hypertrophy (r wave progression),
  3. CXR
    - Alveolar oedema ‘bat wings’
    - Kerley B lines (interstitial oedema)
    - Cardiomegaly
    - Dilated upper lobe vessels
    - Pleural effusion
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11
Q

What is the treatment for acute HF?

A
  1. ABCDE
  2. Loop diuretic infusion or bolus IV (furosemide), add thiazide (bendroflumethiazide) if inadequate
  3. ACEi + BB once stable
    a. Ramipril 1st line; ARB (losartan) or aldosterone antagonist (spironolactone) or hydrazine + nitrate 2nd line; Ivabradine + Digoxin (if EF < 35% and NYHA 2-4) 3rd line
    b. Bisoprolol
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12
Q

What is the general treatment for ACS?

A 
ABCDE 
Morphine 
Oxygen 
Nitrate 
Aspirin 300mg loading dose (5d) 
Fondaparinux 
Ticagrelor 180mg loading dose then 90mg daily
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13
Q

What is the treatment for STEMI?

A
  1. Coronary angiography and PCI if < 12hrs from symptoms onset and within 2 hrs of when thrombosis can be given
  2. Thrombolysis if < 12 hrs from symptoms
  3. Repeat ECG - still ST elevation? –> PCI + Coronary angiography
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14
Q

What is the treatment for NSTEMI?

A
  1. BB (metoprolol short term; atenolol long term)
  2. Risk stratify e.g. GRACE

High risk?

  1. glycoprotein IIb/IIIa
  2. PCI if < 12 hrs symptoms onset, new LBBB
  3. CABG
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15
Q

What are the symptoms of aortic dissection?

A 
Tearing chest pain felt inter or anterior scapular 
Dyspnoea (acute breathlessness) 
Hypotension, syncope + shock 
Unequal pulse 
Unequal BP (>15mmHg between brachial) 
Diastolic murmur (aortic regurgitation)
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16
Q

What are the investigative findings of aortic dissection?

A 
1. CXR:
Wide mediastinum 
Double knuckled aortic arch 
Tracheal deviation to RHS 
Pleural effusion (more on L)
  1. Echo
    Aortic root leak
    Aortic regurgitation
    Pericardial effusion
17
Q

What may an ECG show of a PE?

A

S1 Q3 T3
Tachycardia
BBB
RAD

18
Q

What is the investigative pathway for DVT?

A
  1. Two level Well’s score
    - ≥2 = venous compression USS of leg
    - <2 = D-Dimer (DVT unlikely)
  2. Venous compression USS of leg (90% sensitive + specific)
    - +ve = Anticoagulate immediately
    - -ve = DVT unlikely

Start anticoagulation for 24hrs if USS is not avialbel within 4 hrs

19
Q

What is the treatment for DVT?

A
  1. Anticoagulate
    - LMWH or Fondaparinux or UFH (if severe renal impairment)
  2. Warfarin or NOAC
    - Start within 24hrs of confirmed DVT

If recurrent and extensive DVT

  1. Thrombolysis
    - Catheter directed or Streptokinase
  2. IVC filter
20
Q

What is the investigative pathway of cellultis?

A
  1. Examine leg - look for sign of skin break, measure and monitor leg swelling
  2. Eron classification
    - Classs 3 or 4 must be admitted
21
Q

what is the treatment for cellulitis?

A
  1. Flucloxacillin PO
  2. Phenoxymy-methyl-penicillin or benzypenicillin (if strep confirmed)
  3. Clindamycin, clairithromycin or vancomycin if pen allergic

ACC (13 decks)

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