Resp emergencies

Question 1

What is a pneumothorax

Answer 1

Presence of air in the pleural cavity (between the parietal and visceral pleuraa)

Question 2

What are causes of pneumothorax

Answer 2

• Spontaneous
• Chronic lung disease (COPD, asthma, CF, lung fibrosis, sarcoidosis)
• Infection (TB, pneumonia, lung abscess)
• Trauma (inc iatrogenic)
• Carcinoma
• Connective tissue disease (marfans, ED)

Question 3

What are the two types of pneumothorax

Answer 3

Primary (unknown cause)

Secondary (known cause - common in underlying lung disease, smoker >50)

Question 4

What are symptoms and signs of pneumothorax

Answer 4

SOB
tachypnoea
tachycardia
cyanosis

reduced lung expansion
hyperresonance
decreased breath sounds

Question 5

What are investigations for pneumothorax

Answer 5

Erect PA CXR

CT (gold standard)

Question 6

What are signs in tension pneumothorax

Answer 6

severe resp distress

tracheal deviation to contralat side

Question 7

what causes a tension pneumothorax

Answer 7

formation of a functional valve - lets air into pleural space but not out > mediastinal deviation to contralat side > risk of CARDIAC ARREST

Question 8

How do you measure pneumothorax size

What is the limit size

Answer 8

From the lung margin to the chest wall

2cm

Question 9

If primary pneumothorax: SOB and/or >2cm on CXR

Answer 9

Aspirate

Question 10

What happens if aspiration for primary pneumothorax fails?

Answer 10

Insert chest drain + admit

Question 11

what do you do if primary pneumothorax is small <2cm and no SOB?

Answer 11

reassure, analgesia if necessary, supplemental O2 therapy,

Consider discharge and outpatient review 2 weeks

Question 12

what do you do for secondary pneumothorax >2cm

Answer 12

Chest drain

Question 13

what do you for secondary pneumothorax <2cm

Answer 13

Aspirate. If not successful, chest drani

Question 14

What is the first investigations you do for a suspected PE

Answer 14

CXR, ECG (sinus tachy), ABG (T1RF)

Question 15

How do you use clincial probablity to assess best PE scoring system

Answer 15

low probability: use PERC

medium/high prob: use Well’s score

Question 16

What does a 2 level Wells score tell you

Answer 16

> 4 points: CTPA (or VQ scan)

<=4 points: D dimer

Question 17

What do you do if D dimer is low

Answer 17

safe to exclude PE

Question 18

what do you do if D dimer is high

Answer 18

immediate CTPA

Question 19

what do you do if CTPA is +ve

Answer 19

DOAC

Question 20

what do you do if CTPA is negative

Answer 20

leg USS (for query DVT)

Question 21

How do you manage haemodynamically stable PE

Answer 21

DOAC

• provoked: 3 months
• unprovoked: 6 months

Question 22

what do you do for PE if haemodynamically stable but DOAC is contraindicated

Answer 22

5 days LMWH > dabigatran

OR consider IVC filter

Question 23

What is ARDS

Answer 23

Acute and persistent lung inflammation with increased vascular permeability

Question 24

What are diagnostic criteria for ARDS

Answer 24

Acute onset lung injury
Blateral infiltrates consistent with pulmonary oedema
Resp failure (not explained by HF)
Decreased arterial PaO2/FiO2 ratio

Question 25

What is the commonest cause of ARDS

Answer 25

Sepsis

Question 26

What are key investigations for ARDS

Answer 26

``` Sepsis 6 Bloods CXR, EECG MSU Echo ```

Question 27

How do you manage ARDS

Answer 27

1. Central venous access >inotropes 2. Broad spectrum antibiotics, diuretics 3. Oxygen If non-shocked: sit upright If shocked: colloid infusion

Question 28

Explain PEFR in different types of asthma

Answer 28

life threatening: <33% Severe: 33-50 Moderate: 50-75

Question 29

When do you admit someone with moderate asthma?

Answer 29

never

Question 30

when do you admit someone with severe asthma

Answer 30

If no response to treatment in A&E

Question 31

What are other features of someone with severe asthma

Answer 31

cannot complete full sentences | High RR, high HR

Question 32

What are features of life threatening asthma

Answer 32

``` CHEST Cyanosis Hypotension Exhaustion Silent chest Tachyarrithmia ```

Question 33

When do you admit life threatening asthma

Answer 33

ALWAYS

Question 34

What do you give for severe asthma exacerbation

Answer 34

High flow O Salbutamol 5mg (back to back as req) - neb Itratropium 0.5mg (every 4h) - neb Pred (50mg PO) or hydrocortisone (100mg IV) Senior support: IV mag sulphate, aminophylline, ITU+ intubation

Question 35

What Ix should you get for acute exacerbate of COPD

Answer 35

``` Bloods, sputum pot ABG Blood culture ECG CXR ```

Question 36

How do you manage COPD exacerbate

Answer 36

Oxygen therapy - 24% oxygen via Venturi mask (hypoxia kills quicker than hypercapnia) Nebulisers (salbutamol, itratropium) Prednisolone AND hydrocort Abx (amoxicillin / co-amoxiclav, IV or PO)

Question 37

What is the most common abnormality on ECG with PE, and what other abnormalities can occur?

Answer 37

PE: sinus tachycardia (most common). Otherwise RBBB, S1Q3T3

Question 38

What is the PE Well's Score? summarise all points

Answer 38

EAT CHIP Edema in legs and other S/S = 3 points Alternative dx less likely than PE = 3 points Tachycardia HR >100 = 1.5 points Cancer = 1 point Haemoptysis = 1 point Immobilisation (for 3+ days) or surgery (<4 weeks ago) = 1.5 points Prior DVT/PE = 1.5 points

Question 39

where is the triangle of safety

Answer 39

in axilla superior border = base of axilla Anterior border = lat edge of pec major Posterior border = ant edge of lat dorsi Inferior border = 5th ICS

Question 40

which causes of pneumthorax must you ALWAYS insert a chest drain for

Answer 40

if the cause is TRAUMA or MECHANICAL VENTILATION ALWAYS insert a chest drain