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ICL Block Year 3 > Week 1 - Acute Breathlessness > Flashcards

Week 1 - Acute Breathlessness Flashcards

1
Q

Which systems of the body can be direct causes of chest pain and breathlessness?

A
  • respiratory
  • cardiovascular
  • haematological
  • nervous
  • skeletal
  • muscular
  • digestive
  • endocrine
  • renal
  • psychological
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2
Q

How can the haematological system cause breathlessness?

A

Anaemia reduces ability to carry oxygen due to a lack of RBCs and haemoglobin which can result in breathlessness

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3
Q

How can the nervous system cause breathlessness?

A

Damage to brain/spinal cord (e.g MS and Guillan-Barre) can result in breathlessness

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4
Q

How can the skeletal system cause breathlessness?

A
  • thoracic trauma e.g rib fracture
  • spinal disorders e.g kyphosis, scoliosis can reduce lung expansion
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5
Q

How can the muscular system cause breathlessness?

A

Weakened respiratory muscles due to trauma/neurological etc can cause SOB

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6
Q

How can the digestive system cause breathlessness?

A
  • acute GI bleed can lead to severe anaemia and cause breathlessness
  • GORD leasing to aspiration can cause SOB
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7
Q

How can the psychological system cause breathlessness?

A

Anxiety

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8
Q

How can the endocrine system cause breathlessness?

A
  • thyrotoxicosis (increased metabolic rate) can cause SOB
  • hypothyroidism if left untreated/severe can cause respiratory muscle weakness = SOB and
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9
Q

How can the renal system cause breathlessness?

A

Metabolic acidosis/alkalosis can cause breathlessness

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10
Q

What does haemoptysis mean ?

A

Coughing up blood

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11
Q

What are a list of differential diagnoses for acute breathlessness and chest pain?

A
  • PE
  • pneumothorax
  • pleurisy
  • musculoskeletal chest pain
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12
Q

What are the most common presenting symptoms of lung cancer?

A

Haemoptysis
Chest pain on breathing and/or coughing
Persistent breathlessness
Persistent cough >3 weeks
Persistent tiredness/low energy

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13
Q

Why is COPD an unlikely diagnosis for acute breathlessness ?

A

COPD presents as increasing breathlessness over years not hours

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14
Q

Where is the chest pain felt in Acute Coronary Syndrome (ACS) ?

A

Sharp
On the left side of the chest

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15
Q

What is pleurisy ?

A

Inflammation of the pleura

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16
Q

What does the chest pain of an MI feel like?

A

Central and crushing
Radiating to left arm/shoulder/neck

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17
Q

What causes musculoskeletal pain?

A

Injury to the muscles/bones in the area detected

Usually occurring after some exertion or injury
Exacerbated by movement
Pain can be severe and make patient feel breathless

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18
Q

What is the pain of pleurisy described as?

A

Sharp

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19
Q

What causes the pain of pleurisy?

A

The pleura gets inflamed to the 2 pleural layers start to rub against each other like sand paper with each breath

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20
Q

What causes pleurisy?

A
  • Viral infection (most common)
  • Bacterial infection
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21
Q

What are symptoms of pleurisy?

A
  • pleuritic sharp chest pain
  • cough
  • runny nose or fever
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22
Q

Is pleurisy associated with haemoptysis ?

A

No

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23
Q

What kind of chest pain does a pneumothorax cause?

A

Sudden, sharp chest pain

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24
Q

What are the risk factors of a pneumothorax?

A
  • male
  • smoking
  • underlying lung disease (if secondary spontaneous)
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25
Q

What are the types of pneumothorax?

A
  • simple (trauma)
  • tension (trauma)
  • spontaneous (primary and secondary)
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26
Q

What is the difference between a primary and secondary pneumothorax ?

A

Primary = no apparent cause/no underlying lung disease

Secondary = associated with an underlying lung disease

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27
Q

What symptoms can a PE cause?

A
  • Breathlessness
  • Pleuritic chest pain
  • Haemoptysis (sometimes)
  • Calf swelling
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28
Q

What is a PE?

A

An abnormal thrombus causing a blockage in the pulmonary arteries

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29
Q

What is the most common cause of chest pain in primary care?

A

Musculoskeletal chest pain

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30
Q

What is usually sufficient to treat musculoskeletal chest pain?

A

NSAIDs

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31
Q

What is a key diagnostic tool for differentiating if chest pain is musculoskeletal ?

A

Recreating the patients pain by:
- palpation
- movement

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32
Q

What other conditions must be considered before a diagnosis of Pleurisy is reached?

A
  • PE
  • MI
  • pneumothorax
  • pericarditis
  • pneumonia
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33
Q

What are some viral infections that are associated with causing Pleurisy?

A
  • Corona
  • influenza
  • parainfluenza
  • mumps
  • cytomegalovirus
  • adenovirus
  • Epstein-Barr

there are others but their names are v complicated!

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34
Q

What are some examples of underlying lung pathologies associated with secondary spontaneous pneumothorax?

A
  • asthma
  • COPD
  • lung carcinoma
  • interstitial lung disease
  • CF
    etc
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35
Q

What is the classic presentation of a primary spontaneous pneumothorax?

A
  • sudden onset pleuritic pain
  • dyspnoea at rest
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36
Q

Are symptoms more severe in:
A) primary spontaneous pneumothorax?
B) secondary spontaneous pneumothorax?

Why?

A

More severe in secondary spontaneous pneumothorax

Because lung function may already be compromised due to an underlying pathology.

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37
Q

What is the primary symptomatic complaint from patients suffering a secondary spontaneous pneumothorax?

A

Breathlessness that’s out of proportion to the size of the pneumothorax radiologically

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38
Q

Is alveolar pressure higher or lower than atmospheric pressure during inspiration ?

A

Inspiration = alveolar < atmospheric

to draw air in

39
Q

Is alveolar pressure higher or lower than atmospheric pressure during expiration ?

A

Expiration = alveolar > atmospheric

to draw air out

40
Q

What causes a simple pneumothorax?

A

Trauma/puncture of chest wall and/or lung

41
Q

What type of pneumothorax demands a chest drain ?

A

A simple pneumothorax

42
Q

How does a chest drain work?

A

Acts as a one-way valve to release air from the pleural space during expiration, re-inflating the lung

43
Q

What is the result of a tension pneumothorax ?

A

On inspiration: air drawn into pleural space

On expiration: air is trapped and compressed

this shifts the contents of the mediastinum over to the unaffected side

44
Q

What type of pneumothorax demands needle aspiration ?

A

Tension pneumothorax

45
Q

What is seen characteristically on an X-ray depicting a tension pneumothorax?

A
  • mediastinal/tracheal shift (towards unaffected side)
  • diaphragmatic depression (on affected side)
  • rib cage expansion
46
Q

What is the most common source of pulmonary emboli ?

A

DVTs

47
Q

What are the major risk factors for PE?

A
  • DVT
  • history of previous DVT or PE
  • active cancer
  • recent surgery
  • lower limb trauma
  • long term immobility
  • pregnancy (primarily 6 weeks postpartum)
  • combined oral contraceptives
  • HRT
  • long haul flights
  • obesity
  • increasing age (60+)
48
Q

What is a complication that sometimes follows treatment of a PE?

A

chronic thromboembolic pulmonary hypertension

49
Q

When should PE be considered as a diagnosis?

A

Suspected in people with one or more of:
- breathlessness (dyspnoea)
- pleuritic chest pain
- cough
- haemoptysis
- features of DVT (unilateral leg swelling, redness, venous distension, lower ab pain, raised temp)
- cyanosis
- dizziness and syncope
- tachycardia
- hypoxia
- pyrexia
- gallop rhythm
- pleural rub on auscultation
- hypotension
- shock

50
Q

Are PEs more commonly associated with thrombi above or below the knee?

A

Above the knee

51
Q

What investigation is done in patients with a low probability of having had a PE ?

A

D-Dimer assay (blood test)

52
Q

What investigations are done in patients with a high probability of having had a PE ?

A
  • CTPA scan !!
  • ECHO
  • Troponin
  • ABGs
  • Chest X-Ray
  • ECG
  • PESI score (high risk >80)
53
Q

What is the immediate management of a PE?

A
  • high flow oxygen + IV fluids + analgesics for pleurisy
  • Enoxaparin (1.5mg/kg OD whilst being investigated)
  • if severe: thrombolysis (tPA)
54
Q

What is the long term management after a PE?

A
  • DOAC (Apixaban, Rivaeoxaban, edoxaban)
  • Warfarin
  • inferior vena cava filter (rare, for recurrent VTE despite anticoagulation)
55
Q

What physiological problems can a PE cause?

A
  • Infarction of the lung
  • Hypoxaemia
  • Acute right-side heart failure
  • Hypotension
  • Syncope
  • Circulatory shock
  • Death
56
Q

What’s the most common ECG abnormality ?

A

Sinus tachycardia

57
Q

What features of a primary spontaneous pneumothorax constitutes a pleural aspiration ?

A

Pneumothorax >2cm and/or breathlessness

58
Q

What features of a secondary spontaneous pneumothorax constitutes a chest drain ?

A

Pneumothorax >2cm or breathless

59
Q

What features of a secondary spontaneous pneumothorax constitutes a pleural aspiration ?

A

Pneumothorax 1-2 cm

60
Q

How long after a pneumothorax do most airlines make you wait before flying again?

A

6 weeks

61
Q

What are the reasons a chest drain would stop bubbling ?

A
  • the pneumothorax has resolved
  • the drain is blocked
  • the drain has been pulled out
62
Q

What does it mean if the chest drain has stopped bubbling and it is swinging?

A

The pneumothorax has resolved

63
Q

What does it mean if the chest drain has stopped bubbling and is not swinging?

A

The drain has either been pulled out or blocked

64
Q

What should you do if the chest drain has stopped bubbling and is not swinging?

A
  • check the site
  • request an X-ray

If tube not in pleural cavity: reposition the chest drain

If tube still in pleural cavity: flush tube with aseptic technique with 10ml saline to unblock it

65
Q

Anticoagulant therapy can be a cause of haemoptysis, would it also be associated with pleuritic chest pain and breathlessness?

A

No anticoagulant therapy is not associated with chest pain and breathlessness

66
Q

When is a lactate test indicated?

A

When there is suspicion of sepsis

67
Q

What is the definitive investigation to diagnose a PE?

A

CTPA

68
Q

What investigations would you do to confirm a PE if the Wells score is suggesting high risk?

A
  • CTPA
  • chest X-Ray
  • ECG
  • ABGs
  • routine blood tests (renal, liver function

if pneumonia is also in differentials then perform a CRP

69
Q

What features may be present on the X-Ray of a PE patient?

A
  • normal is most common
  • small pleural effusions
70
Q

When do you perform a D-Dimer ?

A

If the patient’s Wells score is suggesting low risk of having had a PE

71
Q

What is the initial treatment for a potential PE patient, prior to performing a confirmatory CTPA?

A
  • analgesia
  • treatment dose LMWH
72
Q

How do clots present on a CTPA?

A

As grey abnormalities surrounded by white contrast

73
Q

What is anaphylaxis?

A

A life threatening type 1 hypersensitivity reaction causing mass release of histamine into blood stream

74
Q

How do we differentiate an anaphylactic reaction from an allergic reaction?

A

Anaphylaxis reactions include:
- airway problems and/or
- breathing problems and/or
- circulation problems

75
Q

What is an airway problem found during anaphylaxis?

A

Stridor = laryngeal oedema

Caused by leaky capillaries in response to histamine

76
Q

What is a breathing problem found during anaphylaxis?

A

Wheeze = bronchospasm

Caused by histamine binding to H1 receptors in the lungs

77
Q

What is a circulatory problem found during anaphylaxis?

A

(Pre)syncope = hypotension

Caused by leaky capillaries in response to histamine

78
Q

How do we initially manage anaphylaxis ?

A
  • assess using ABCDE
  • call for help from resus team
  • remove the trigger
  • lie patient flat/recovery position
  • IM adrenaline (1mg/ml; give 500mcg=0.5ml of 1:1000)
  • give oxygen
  • IV fluids bolus (500-1000ml)
79
Q

When do you not perform a CTPA?

A
  • where renal function is significantly impaired
  • pregnant women
  • known contrast allergy
80
Q

What would you do instead of a CTPA if it is contraindicated ?

A
  • a Doppler ultrasound of the legs to look for VTE
  • ventilation/perfusion scan
81
Q

What does a flattened inter-ventricular septum suggest in a PE patient?

A

Right heart strain

82
Q

What is considered a very low risk PESI score?

A

65 or less

83
Q

What is considered a low risk PESI score?

A

66-85

84
Q

What is considered an intermediate risk PESI score?

A

86-105

85
Q

What is considered a high risk PESI score?

A

106-125

86
Q

What is considered a very high risk PESI score?

A

> 125

87
Q

When should a PE clinic follow up be conducted ?

A

After 3 months

88
Q

What are the most common reactions to anticoagulation therapies?

A

Bleeding
Bruising
Nausea
Anaemia

89
Q

What are the first line anticoagulants for patients with confirmed PE?

A

Apixaban
Rivaroxaban

90
Q

What anticoagulants do you prescribe if first line treatments aren’t suitable ?

A
  • LMWH for at least 5 days, followed by dabigatran or edoxaban

Or

  • LMWH concurrently with Warfarin (VKA) until therapeutic anticoagulation is achieved
91
Q

What are the contraindications of rivaroxaban ?

A
  • Pregnancy
  • Cirrhosis with coagulopathy
92
Q

What sound on auscultation is suggestive of a PE ?

A

Pleural rub

Because a PE irritates the pleura, inflaming it and leading to pleural rub sounds

93
Q

What do patients with Marfan syndrome have an increased risk of developing?

A

Pneumothorax

94
Q

What are some features of Marfan Syndrome?

A
  • tall, slender build
  • disproportionately long arms/legs/fingers
  • protruding or inverted breast bone
  • crowded teeth
  • heart murmurs
  • extreme near sightedness
  • abnormally curved spine
  • flat feet

ICL Block Year 3 (4 decks)

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