PE, Pneumothorax and Pleural Effusion Flashcards Preview

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Flashcards in PE, Pneumothorax and Pleural Effusion Deck (24)
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1

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

2

Rarer causes of PE

Right ventricular thrombus (after MI)
Right atria from AF
Septic emboli (right-sided endocarditis)
Fat (long-bone fracture)
Neoplastic cells

3

Risk factors for PE

Recent surgery (especially abdo/pelvis)
Thrombophilia
Leg fracture
Prolonged bed rest/immobility
Malignany
Pregnancy/post partum, HRT/OCP
Previous PE

4

Symptoms of PE

Depend on size
Pleuritic chest pain
Acute breathlessness
Haemoptysis
Dizziness
Syncope

5

Signs of PE

Pyrexia, cyanosis
Tachycardia, tachypnoea
Hypotension
Raised JVP
Pleural rub
Pleural effusion

6

CXR in PE

May be normal
May show oligaemia of affected segment
Dilated pulmonary artery
Liner atelectasis
Small pleural effusion

7

ECG in PE

May be normal
Or may have
Tachycardia
RBBB
right ventricular strain

8

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

9

PE Prevention

Heparin to all immobile patients
TED stockings
Encourage early mobilisation
Stop HRT and OCP pre-op

10

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)

11

Most common cause of pneumothorax

Spontaneous - especially in young thin men
Due to rupture of a sub-pleural bulla

12

Other causes of pneumothorax

Underlying lung pathology
Trauma
Iatrogenic - subclavian CVP line insertion, pleural aspiration/biopsy, liver biopsy

13

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

14

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

15

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

16

Signs in pneumothorax

Reduced expansion unilaterally
Hyperresonant percussion
Reduced breath sounds
Reduced vocal fremitus

Tachypnoea - pain, anxiety or response to hypoxia
Tachycardia

17

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

18

CXR in pneumothorax

Tension - tracheal deviation
Reduced lung - can see air where collapsed lung usually is

19

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

20

Management if more than 20% radiographic volume in primary pneumothorax

Aspirate air
If no recurrence, send home
If recurs - insert chest drain

21

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

22

What to do if pneumothorax remains or if tube bubbling

Or recurrent pneumothorax

Pleurectomy - no recurrence
Talc pleurodesis - some recurrence

23

Management of secondary pneumothorax with >2cm rim of air on CXR

Chest drain
If less than 2cm - aspirate

24

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