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Yr3 Medicine- Respiratory > Pleural Effusion, Pneumothorax, PE, Massive Haemopytsis > Flashcards

Pleural Effusion, Pneumothorax, PE, Massive Haemopytsis Flashcards

1
Q

What is a pleural effusion?

A

Fluid in pleural cavity

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2
Q

The fluid in a pleural effusion can be transudate or exudate; state the pathophysiology behind a transudate pleural effusion and state some causes of transudate pleural effusions

A

Transudate (idea that fluid moves out of veins due to increased hydrostatic or decreased oncotic presure)

  • Increased venous pressure e.g. cardiac failure, constrictive pericarditis, mitral stenosis, fluid overload, pulmonary embolism
  • Hypoproteinaemia e.g. liver cirrhosis, nephrotic syndrome, malabsorption
  • Hypothyroidism
  • Meig’s syndrome (right sided pleural effusion & ovarian fibroma)
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3
Q

The fluid in a pleural effusion can be transudate or exudate; state the pathophysiology behind a exudate pleural effusion and state some causes of exudate pleural effusions

A

Exudate (idea that vessels become leaky)

  • Infection e.g. pneumonia, TB
  • Inflammation e.g. pulmonary infarction, RA, SLE, following CABG (Dressler’s syndrome)
  • Malignancy
  • Pancreatitis
  • Connective tissue disease
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4
Q

What are the 4 most common causes of pleural effusion?

A
  • Pneumonia
  • Malignancy
  • Congestive heart failure
  • Following CABG
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5
Q

State the symptoms of a pleural effusion

A
  • Dyspnoea
  • Pleuritic chest pain
  • Cough
  • Asymptomatic
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6
Q

What might you find on clinical examination of someone with a pleural effusion

A
  • Tachypnoeic
  • Decreased expansion on affected side
  • Stony dull percussion note on affected side
  • Diminished breath sounds on affected side
  • Vocal resonance reduced on affected side
  • Above the effusion may be bronchial breathing (where lung is compressed due to effusion)
  • Tracheal deviation (large effusion)
  • Signs of the underlying cause of pleural effusion e.g. malignancy, pneumonia, congestive heart failure
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7
Q

What investigations would you want if you suspect pleural effusion, include:

  • Bedside
  • Bloods
  • Imaging
A

Bedside

  • ECG: if suspect heart failure
  • Diagnostic tap/needle aspiration check if exudate or transudate. If exudate can help indicate cause as send for cytology, culture, glucose etc…

Bloods

  • FBC: WCC for infection
  • U&Es: renal func
  • LFTs: liver func
  • CRP: inflammation
  • Bone profile:
  • LDH: to compare serum LDH and pleural LDH
  • Clotting

Imaging

  • CXR: visualise pleural effusion
  • Ultrasound: sensitve for pleural septations which occur in exudates
  • ?ECHO: if suspect heart failure
  • ?Staging CT with contrast: to investigate underlying cause if it is exudate
  • ?Thoracocopy or CT pleural biopsy
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8
Q

What would you see on CXR of someone with pleural effusion?

A
  • Blunting of costophrenic angle
    • Larger effusions will have meniscus
  • Fluid in fissures
  • If massive effusion may see mediastinal shift & tracheal deviation
  • Underlying cause of effusion e.g. pneumonia, tumour etc..
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9
Q

If you aspirated a pleural effusion, what would you then test it for?

A
  • pH
  • Protein
  • LDH
  • Cytology
  • Microbiology
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10
Q

You should never insert a chest drain unless the diagnosis is well established (e.g. known lung cancer) as draining all fluid may hinder opportunity to obtain biopsies. What is the only indication for an urgent chest drain?

A

Urgent chest drains are only indicated in empyema

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11
Q

Which pleural effusion pts would you NOT do a diagnostic tap on?

A

If there is a well known established underlying cause and no atypical features you do not need to do diagnostic tap e.g. in known congestive heart failure.

Diagnosit taps are often not required for transudates.

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12
Q

For each of the following, state what pathology it suggests if this is what you see when you do the diagnostic tap/aspiration:

  • Yellow/pus
  • Blood
  • Milky colour
A
  • Yellow/pus= empyema (ph<7.2, low glucose, high WCC, high LDh)
  • Blood= pulmonary infarction or malignancy (may also be due to trauma from apsiration)
  • Milky colour= chylothorax
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13
Q

How do you differentiate between transudate and exudate on the basis of pleural protein?

A
  • Transudate: pleural protein <25g/L
  • Exudate: pleural protein >35g/L
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14
Q

If the pleural protein level, of a pleural effusion aspiration, is between 25-35g/L what criteria do you use to distinguish if it is transudate or exudate?

A

Light’s criteria

Effusion is exudate if any one of the following is true:

  • Effusion protein/serum protein ratio >0.5
  • Effusion LDH/serum LDH ratio >0.6
  • Effusion LDH more than 0.6 x the upper limit of normal
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15
Q

Discuss the management of pleural effusions

A
  • Treat underlying cause
  • If treating underlying cause does’t solve effusion consider:
    • Needle aspiration
    • Chest drain
    • Pleurodesis or indwelling catheter (if going to get recurrent pleural effusions e.g. due to malignancy)
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16
Q

Remind yourself of where you insert a chest drain

A
  • 5th ICS (just above 6th rib)
  • Mid axillary line
  • In ‘safe triangle’ (between lateral edge of pec major, lateral edge of lat dorsi and nipple line)
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17
Q

How much fluid needs to be present in pleural effusion for it to be visible on CXR?

A

~200ml

(normally contains ~10ml)

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18
Q

Ultrasound can detect smaller effusions than CXR (which requires a pleural effusion to have ~200ml fluid to be seen); how many mls of pleural effusion are required for it to be visualed on ultrasound?

A

Ultrasound can identify amounts as small as 5-10mls of fluid; but we usually say it requires about 20mls of fluid to ensure relability.

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19
Q

What is a pneumothorax?

A

Air in pleural cavity

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20
Q

Discuss the different types of pneumothorax- include brief description of why each occurs

A

Types of pneumothorax:

  • Spontaneous:
    • Primary: no underlying lung disease. Rupture of sub pleural bulla
    • Secondary: underlying lung disease which has predisposed to pneumothorax
  • Traumatic: penetrating or blunt injury to chest
  • Tension pneumothorax: pneumothorax which is causing mediastinal shift and cardiovascular collapse
  • Iatrogenic: caused by medical procedure e.g. post central line or pacemaker insertion, +ve pressure ventilation
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21
Q

State some risk factors for developing a pneumothorax

A
  • Pre-existing lung disease (spontaneous secondary)
  • Height (spontaneous primary common in tall young males)
  • Smoking
  • Cannabis
  • Diving (changes in pressure)
  • Trauma
  • Procedure involving chest
  • Other conditions e.g. Marfan’s
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22
Q

State some lung conditions that may predispose some to/increase risk of a pneumothorax

A

COPD, pneumonia, TB, cystic fibrosis, carcinoma, lung fibrosis, sarcoidosis, connective tissue disorders

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23
Q

Who are spontaneous primary pneumothoraxes common in?

A

Tall, young, thin males.

Smoking increases risk

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24
Q

Discuss how someone with a pneumothorax will present- think about how different pts will present e.g. young & fit, asthmatic or COPD, ventialted pt etc…

A

Degree of symptoms can vary from asymptomatic (if young, fit and pneumothorax small) to having varying degrees of the following dyspnoea and/or pleurtic chest pain.

Pts with COPD or asthma may present with sudden deterioration.

Ventilated pts may present with hypoxia or increased ventilation pressures

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25
Q

What might you find on clinical examination of someone with a pneumothroax?

A
  • Reduced chest expansion on affected side
  • Reduced breath sounds on affected side
  • Hyperesonant percussino on affected side
  • Hypoxia
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26
Q

What investigations would you want for someone with a suspectd pneumothorax, include:

  • Bedside
  • Bloods
  • Imaging

*For each, justify why you are doing it

A

Bedside

  • ?ABG: particularly important to guide O2 therapy in COPD pts

Bloods

  • FBC: WCC, Hb
  • CRP: ?infection
  • Coagulation screen: correct clotting abnormalities, if pt stable, before inserting chest drain

Imaging

  • CXR: look for reduced lung markings around edges
27
Q

What would you see on CXR of someone with pneumothorax?

A
  • Visible rim between lung margins and chest wall
  • Absence of lung markings between lung margin and chest wall
  • Surgical emphysema
28
Q

What does surgical/subucutaneous emphysema look like on CXR?

A

Black patches/shadowing where should be a more solid grey

Compare image on this side of card with image of normal CXR on other side of card

29
Q

Discuss the management of a pneumothorax

A

As per BTS guidelines:

  • Managment of spontaneous primary:
    • If SOB and/or rim of air >2cm on CXR give O2 and aspirate
    • If unsucessful, consider reaspiraton or chest drain
    • If persistent air leak >5 days refer to thoracic surgeons (most likely due to bronchopleural fistula)
  • Management of spontaneous secondary or if >50yrs with significant smoking history:
    • SOB and/or >2cm → chest drain
    • 1-2cm → try aspirate
    • <1cm → admit for 24hrs for observation & O2
  • Managment of traumatic/iatrgoenic:
    • Aside from oxygen further management should be decided by thoracic surgeon: will be either chest drain or thoracotomy
    • DO NOT ASPIRATE TRAUMATIC PNEUMOTHORAX!
    • Monitor closely for deveoplment of tension pneumothorax
30
Q

What discharge advice would you give to a pt who has had a pneumothorax?

A

Smoking

  • Stop smoking
  • CAA suggest patients can travel 2 weeks after successful drainage if no residual air. BTS used to say no flying for 6 weeks but this has been changed to 1 week post check x-ray
  • Permanently avoid scuba diving unless undergone b/l pleurectomy with normal lung function & CT
31
Q

State some potential complications of a pneumothorax

A

Tension pneumothorax main one to be aware of

32
Q

Discuss the reoccurence of both spontaneous primary and spontaneous secondary pneumothoraxes

A

Pts with spontaneous primary pneumothorax have 30-50% chance of recurrent pneumothorax on ipsilateral side

Pts with spontaneous secondary pneumothorax are at greater risk of reccurence; lung disease often affects both lungs hence risk of contralateral pneumothorax.

33
Q

State the symptoms of a tension pneumothorax

A
  • Severe dyspnoea
  • Pleuritic chest pain
  • Fatigue

(Similar to symptoms of tension pneumothorax but more intense)

34
Q

State what you might find on clinical examination of someone with a tension pneumothorax

A
  • Tachycardia
  • Hypotension
  • Raised JVP
  • Displaced apex beat
  • Tracheal deviation
  • Reduced/absent breath sounds on affected side
  • Hyper-resonant percussion note
35
Q

Discuss the management of a tension pneumothorax

A
  • IMMEDIATELY insert large bore needle or cannula in 2nd ICS in midclavicular line on side of pneumothorax. Do not wait for CXR. Put out a peri-arrest call too. Follow this with a chest drain.
  • Oxford handbook also mentions: Insert large bore (14-16G) needle with a syringe- partially filled with 0.9% saline- into the 2nd ICS in midclavicular line on the side of the pneumothorax. Remove plunger and allow air to bubble through saline (with saline acting as a water seal)*
36
Q

State some potential complications of a tension pneumothorax

A
  • Cardiac arrest
  • Hypoxia
  • Shock (mechanical- heart
  • Resp failure
37
Q

Define the following:

  • Empyema
  • Pleural plaque
  • Pleural thickening
  • Pleural tumour
A
  • Empyema: infected fluid in pleural cavity
  • Pleural plaque: discrete fibrous areas of pleura (hence thickened pleura) due to long term exposure to asbestos
  • Pleural thickening: larger areas of scarring/calcification causing thickening (benign or malignant)
  • Pleural tumour: abnormal growth of tissue in pleura that can be beningn or malignant
38
Q

What is a para-pneumonic effusion? Discuss how we manage these

A

Para-pneumonic effusion is an effusion that occurs alongside pneumonia. We stage them I-IV. As a general rule of thumb stages I & II are not infected and stages III & IV are infected/classify as empyema and hence require urgent chest drain alongside the empirical antibiotics. Empirical antibiotics used for all stages of para-pneumonic effusion (as you need antibiotics to treat the pneumonia)

39
Q

Discuss the difference between pleural plaque and pleural thickening

A
  • Pleural plaque is a discrete fibrous,thickened area.
  • Pleural thickening is larger areas of scarring & thickening
40
Q

You do not wait for a CXR in a suspected tension pneumothorax; however, if a CXR was done what would you see?

A
  • Tracheal deviation
  • Medialstinal shift
  • Absent lung markings around periphery (where air is in pleural space)
41
Q

What is a pulmonary embolism?

A

Thrombi that has embolised and is occluding pulmonary vasculature

42
Q

Discuss the pathophysiology of a PE/why it is an emergency

A
  • Thrombus forms in deep vein of leg
  • Embolises to right side of heart
  • Lodges in pulmonary vasculature
  • Occludes blood flow through pulmonary vasculature
  • Increases RV pressure
  • Decreases blood return to left side of heart (decrease preload)
  • Decrease cardiac output
43
Q

State some risk factors for developing a PE

A
  • Surgery within last 2 months: abdo/pelvic, knee/hip replacement, post-op ITU admission
  • Obstetric: late pregnancy, caesarian section, post natal
  • Lower limb: fracture, varicose veins
  • Malignancy: abdo/pelvic/advanced/metastatic
  • Reduced mobility
  • Previous proven VTE
  • Family history
  • Inherited thrombophilia factor V Leiden mutation, antiphospholipid syndrome, antithrombin deficiency, protein C or S deficiency

The above are strong risk factors, below are some more:

  • IBD
  • Recent flight
  • Oral hormone replacement, COCP
44
Q

State the symptoms of a pulmonary embolism

A
  • Acute dyspnoea
  • Pleurtic chest pain
  • Haemoptysis
  • Syncope
  • DVT symptoms: unilateral leg swelling, pain, red & discoloured skin, warm to touch
45
Q

State what you might find on clinical examination of someone with a PE

A
  • Hypotension
  • Tachycardia
  • Raised JVP
  • Loud P2
  • Right ventricular heave
  • Pleural rub
  • Tachypnoea
  • Hypoxaemia
  • Cyanosis
  • DVT signs: swelling, tender, hot to touch, red or discoloured
  • Gallop rhythm
46
Q

If you have a high suspicion of a PE, before you decide what investigations to do you calculate a score. What score do you calculate and describe both the components of this score and what each score means?

A

Calculate PE Wells score:

  • Score = 4 PE is unlikely hence do D-dimer and if D-dimer +ve consider CTPA
  • Score >4 PE is likely hence do CTPA and don’t bother waiting for D-dimer

*Remember, there is another wells score specifically for DVT and this has a lower score threshold of 2

47
Q

What investigations would you do for someone with suspected PE, include:

  • Bedside
  • Bloods
  • Imaging

*For each, justify why

A

Bedside

  • ECG: look for signs of PE on ECG
  • ?ABG

Bloods

  • FBC: may indicate thrombocythaemia or polycythaemia which can increase risk. Thrombocytopenia or anaemia may have increased bleeding risk. Measure baseline
  • U&Es: baseline renal func to help with drug doses and also to think about risk of contrast induced nephropathy from CTPA
  • Coagulation: establish basline before anticoagulation
  • D-dimer: raised in PE but also raised in lots of other things. If Wells score >4 we don’t use D-dimer results anyway
  • LFTs: baseline values- for drug purposes

Imaging

  • CTPA (first line):show embolism in pulmonary vasculature
  • VQ scan (if pt cannot have CTPA- depends if centre has VQ scanner)
  • ECHO (if pt cannnot have CTPA): look for right ventricular dysfunction which is suggestive of PE. Also helps assess severity
  • CXR: rule out pneumothorax and other pathology
48
Q

What might you find on the ECG of someone with a PE?

A
  • Classic PE pattern (rare)
    • Deep S wave in lead I
    • Deep Q wave in lead III
    • Inverted T wave in lead III
  • RBBB
  • Right ventricular strain (ST depression or inverted T waves in V1-V4. May also see the pattern in inferior leads)
49
Q

State some causes of raised D-dimer

A

Idea lots of things. Hence, positive D-dimer doesn’t mean it is PE. Equally, if D-dimer is negative and pt is high risk/high clinical suspicion of PE it doesn’t rule out PE. Can only rule out PE if clinical suspicion is low and D-dimer is low

50
Q

Once you have diagnosed a pt with a PE, what score can you use to determine how best to manage pt? Discuss the components involved in the scoring system and what the different results mean

A

PESI (pulmonary embolism severity score) can be utilized to determine mortality and long term morbidity; help you determine whether to manage as outpatient, inpatient or get ITU involved.

Scores:

  • <65 = very low risk
  • 66-85= low risk
  • 86-105= intermediate risk
  • 106-125= high risk
  • >125= very high risk
51
Q

DOACs are often preferred to warfarin; in what pts would we still give warfarin?

A

Give warfarin to pts with anti-phospholipid syndrome

52
Q

Discuss the management of PE if pt, after your A-E assessment, is haemodynamically stable (include drug choice and length of treatment in answer)

A

Drug Choice

  • NICE recommend using a DOAC (apixaban or rivaroxaban) if PE suspected and continue if diagnosis confirmed (in 2020 guidance changed from LMWH initially to being able to use DOACs. Guidance also used to state cancer pts had to have LMWH but can now have DOACs)
  • If apixaban or rivaroxaban not suitable, can do either LMWH followed by dabigatran or edoxaban OR LMWH followed by a vitamin K antagonist (warfarin)
  • If have antiphospholipid syndrome, must have LMWH followed by vitamin K antagonist
  • If severe renal impairment, LMWH may be used (check BNF if low renal function)

Duration of treatment

  • If wad provoked → anticoagulate for 3 months then assess
  • If was unprovoked→ anticoagulate for 6 months then reassess balancing risk of further thrombosis/emboli with bleeding risk. In reality, most pts with unprovoked VTE are on life long anticoagulation as long as bleeding risk does not outweigh
  • Pt has persistent thrombotic risk and/or previous emboli should be anticoagulated for life
  • Cancer associated → 6 months then review
53
Q

What is the target INR for pts being treated with warfarin for VTE?

Discuss whether bridging is required when switching from LMWH to warfarin

A
  • Target INR: 2-3
  • When switching to warfarin continue LMWH for 5 days or the INR is 2-3 for 24 hours on warfarin (whichever is longer).
54
Q

Why do we give heparin in a PE?

A
55
Q

Discuss the management of a PE in a pt, who after your A-E assessment, has a massive PE and is haemodynamically unstable

A
  • Oxygen if hypoxic
  • Fluids is hypotensive
  • Thrombolysis with fibrinolytic medication (e.g. alteplase, streptokinase, tenecteplase). This can be given IV via cannula or directly into pulmonary arteries via catheter directed thrombolysis.
56
Q

State some signs of a massive PE

A
  • Hypotension/immenent cardiac arrest
  • Signs of right sided heart strain on CT or ECHO
57
Q

You should consider thrombolysis- even if pt hasn’t had any imaging- if there is substantial clinical suspicion of massive PE and cardiac arrest is imminent; true or false?

A

True

58
Q

Thrombolysis is high risk hence you must ensure there are no contraindications; state some absolute and some relative contraindications

A

Absolute

  • Haemorrhagic or ischaemic stroke in <6 months
  • CNS neoplasms
  • Recent major trauma/surgery/head injury
  • Gastrointestinal bleeding <1 month
  • Known bleeding risk/bleeding disorder
  • Aortic dissection

Relative

  • Warfarin
  • Pregnancy
  • Advanced liver disease
  • Infective endocarditis
59
Q

State some complications of thrombolysis

A
  • Bleeding
  • Hypotension
  • Intracranial haemorrhage/stroke
  • Reperfusion arrhythmias
  • Systemic embolisation of thrombus
  • Allergic reaction
60
Q

State some potential complications of a PE

A
  • Death
  • Pulmonary infarction
  • Bleeding (treatment)
  • Heparin associated immune thrombocytopenia
  • Recurrent venous-thrombolic event
61
Q

How do we define massive haemoptysis?

A
  • >240mls in 24hr
  • >100mls/day over consecutive days
62
Q

Discuss the management of massive haemoptysis

A
  • ABCDE
  • Lie pt on side of suspected lesion (if known)
  • Oral tranexamic acis for 5 days (or IV)
  • Stop any precipitating drugs e.g. aspirin, NSAIDS, anticoagulants
  • Give Abx if evidence of infection
  • Consider vit K
  • CT aortogram (intervential radiologist may be able to undertake bronchial artery dissection)
63
Q

NICE summary DVT

A
64
Q

NICE summary PE

A

Yr3 Medicine- Respiratory (11 decks)

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