PE, Pneumothorax and Pleural Effusion Flashcards
(24 cards)
What usually causes a PE?
Venous thrombosis from the pelvis or leg, clot breaks off and travels through the heart and lodges in pulmonary circulation
Rarer causes of PE
Right ventricular thrombus (after MI) Right atria from AF Septic emboli (right-sided endocarditis) Fat (long-bone fracture) Neoplastic cells
Risk factors for PE
Recent surgery (especially abdo/pelvis) Thrombophilia Leg fracture Prolonged bed rest/immobility Malignany Pregnancy/post partum, HRT/OCP Previous PE
Symptoms of PE
Depend on size Pleuritic chest pain Acute breathlessness Haemoptysis Dizziness Syncope
Signs of PE
Pyrexia, cyanosis Tachycardia, tachypnoea Hypotension Raised JVP Pleural rub Pleural effusion
CXR in PE
May be normal May show oligaemia of affected segment Dilated pulmonary artery Liner atelectasis Small pleural effusion
ECG in PE
May be normal Or may have Tachycardia RBBB right ventricular strain
Treatment of PE
Anticoagulate - LMWH
Start warfarin and then stop heparin when INR >2
Continue warfarin for at least 3 months aiming for an INR of 2-3
Thrombolyse if massive PE - alteplase 10mg IV over 1min then 90mg IV over 2h
PE Prevention
Heparin to all immobile patients
TED stockings
Encourage early mobilisation
Stop HRT and OCP pre-op
When perform a D-Dimer in PE diagnosis
Only if patient without a high probability of PE
Negative D-dimer will exclude PE
+ve D-dimer does not give diagnosis - will need imaging as well to confirm (CTPA)
Most common cause of pneumothorax
Spontaneous - especially in young thin men
Due to rupture of a sub-pleural bulla
Other causes of pneumothorax
Underlying lung pathology
Trauma
Iatrogenic - subclavian CVP line insertion, pleural aspiration/biopsy, liver biopsy
Risk factors for pneumothorax
Physical height - increased distending pressure on alveoli
Smoking increases risk of first spontaneous pneumothorax by 20x in men and nearly 10x in women
Underlying lung disease eg. COPD
Main physiological consequences of a pneumothorax
Decreased vital capacity and paO2
Young and otherwise healthy can tolerate this well and may have minimal signs
But underlying lung disease may develop respiratory distress
Clinical Features of pneumothorax
Sudden onset dyspnoea
Sudden onset chest pain (tearing of pleura, bleeding into pleural space)
If asthma or COPD - will present as sudden deterioration
Signs in pneumothorax
Reduced expansion unilaterally
Hyperresonant percussion
Reduced breath sounds
Reduced vocal fremitus
Tachypnoea - pain, anxiety or response to hypoxia
Tachycardia
What happens in tension pneumothorax
One way valve therefore air continues to enter pleural space - pressure builds up and mediastinum displaces
CO drops due to decreased cardiac filling - urgent ventilation required
Distended neck veins
CXR in pneumothorax
Tension - tracheal deviation
Reduced lung - can see air where collapsed lung usually is
Management of pneumothorax if patient is stable
Small rim of air seen with minimal symptoms
Avoid strenuous exercise and observe at 2-weekly intervals until air is resorbed
Management if more than 20% radiographic volume in primary pneumothorax
Aspirate air
If no recurrence, send home
If recurs - insert chest drain
Aspiration of pneumothorax
2nd intercostal space midclavicular line or 4th-6th midaxillary line
Infiltrate 1% lidocaine down to pleura overlying pneumothorax
Insert 16G cannula
Aspirate up to 2.5L of air - stop if resistance is felt or if patient coughs excessively
CXR to check resolution 2h and 2week later
What to do if pneumothorax remains or if tube bubbling
Or recurrent pneumothorax
Pleurectomy - no recurrence
Talc pleurodesis - some recurrence
Management of secondary pneumothorax with >2cm rim of air on CXR
Chest drain
If less than 2cm - aspirate
Management of tension pneumothorax
Medical emergency
Insert a large-bore needle (14-16) with syringe into 2nd intercostal space mid clavicular line
Remove plunger and allow trapped air to bubble through syringe (with saline in it as water seal)
This is until chest drain can be put in place
THEN AFTER THIS - request Chest xray
