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    Respiratory Emergencies: Amy Bullock Amy - Bullock@students - Plymouth.ac - Uk

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    Thea Bertea
    A 60 year old man presented with sudden onset shortness of breath and chest pain. On examination, he had reduced breath sounds and hyperresonance on the right side of his chest. Differentials included pneumonia, pulmonary embolism, and pneumothorax. A chest x-ray showed opacity in the right lung, consistent with pneumonia. The patient was treated with antibiotics and supplemental oxygen.

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    Respiratory Emergencies: Amy Bullock Amy - Bullock@students - Plymouth.ac - Uk

    Uploaded by

    Thea Bertea
    122 views34 pages
    A 60 year old man presented with sudden onset shortness of breath and chest pain. On examination, he had reduced breath sounds and hyperresonance on the right side of his chest. Differentials included pneumonia, pulmonary embolism, and pneumothorax. A chest x-ray showed opacity in the right lung, consistent with pneumonia. The patient was treated with antibiotics and supplemental oxygen.

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    Respiratory Emergencies

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    A 60 year old man presented with sudden onset shortness of breath and chest pain. On examination, he had reduced breath sounds and hyperresonance on the right side of his chest. Differentials included pneumonia, pulmonary embolism, and pneumothorax. A chest x-ray showed opacity in the right lung, consistent with pneumonia. The patient was treated with antibiotics and supplemental oxygen.

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    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    122 views34 pages

    Respiratory Emergencies: Amy Bullock Amy - Bullock@students - Plymouth.ac - Uk

    Uploaded by

    Thea Bertea
    A 60 year old man presented with sudden onset shortness of breath and chest pain. On examination, he had reduced breath sounds and hyperresonance on the right side of his chest. Differentials included pneumonia, pulmonary embolism, and pneumothorax. A chest x-ray showed opacity in the right lung, consistent with pneumonia. The patient was treated with antibiotics and supplemental oxygen.

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    © All Rights Reserved
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    of 34

    Respiratory

    emergencies
    Amy Bullock
    [email protected]
    • What’s happening •Travel history
    HISTORY • How long for
    • Pain – SOCRATES - •PMHx
    worse on inspiration?
    • SOB •Medications
    • Cough
    •FHx
    • Sputum
    • Haemoptysis •Social history
    • Noisy breathing –
    stridor, wheeze
    • General inspection: do they
    look well?
    • Hands: clubbing, cyanosis,
    tremor, tar staining
    • Arms: blood pressure, RR
    EXAM • Face: cyanosis, pallor
    • Neck: swellings, lymph node
    examination, trachea
    • Chest: look, listen, feel
    • Legs: swelling, red, hot,
    • Haemoptysis
    • Cough >3weeks
    Red flags • Long smoking history
    • Unintentional weight loss
    • Night sweats
    • Persistent fevers
    • Reduced saturations
    19yr old Jake - very short of breath. Cannot
    complete full sentences so difficult to get a
    thorough history. Had a bit of a cold for past
    few days but normally fit and well.
    • PMHx: asthma, nil else

    Case 1 • Meds: Ventolin, Fostair


    • On examination, widespread bilateral
    wheeze, not cyanosed.
    • No angioedema, no urticaria

    • RR 32, HR 125, BP 120/80, T37, SpO2 93%,


    Differentials
    • Asthma exacerbation
    • Anaphylaxis
    • Foreign body
    • PE
    Cannot complete full sentences
    Not cyanosed
    Asthma exacerbation – severity Wheezy throughout
    RR 32, HR 125, BP120/80, SpO2 93%,

    MODERATE LIFE THREATENING


    • PEF >50-75% best • PEF <33%
    • SpO2 <92% // PaO2< 8kPa
    • Silent chest
    SEVERE ACUTE • Cyanosis
    • PEF 33-50% best • Poor resp effort
    • RR >/=25 • Arrhythmia
    • HR >/=110 • Exhaustion
    • Unable to complete sentences • Altered consciousness
    • Hypotension
    Asthma
    exacerbations are life
    threatening
    In 2018 – 1422 deaths
    3 people die every day with
    an asthma attack
    Management – OSPIT
    • Pre hospital – 10puffs of reliever inhaler (SPACER), often have an instruction sheet to guide them

    • O2 at 94-98%
    • Salbutamol nebulisers 5mg – oxygen driven
    • Prednisolone 40-50mg for 5 days
    • Ipratropuim bromide nebs 0.5mg 4-6hourly
    • IV magnesium sulphate
    • IV aminophylline
    • Intubation ventilation

    • Admit AND follow up


    Asthma vs COPD exacerbation management

    Asthma COPD – infective or non infective


    • Oxygen 94-98% • Oxygen, need to identify whether CO2
    retainer
    • Salbutamol nebs
    • Salbutamol OR saline nebs
    • Prednisolone 40-50mg 5days • Prednisolone 30mg 5-7days
    • Ipratropium bromide nebs • Ipratropium bromide nebs
    • IV magnesium sulphate • Antibiotics; amoxicillin/ doxycycline/
    clarithromycin

    • NIV, IV theophylline
    Case 2
    • 1400  30F left sided chest pain, stabbing, sudden onset 7am but worsening –
    now 7/10. Worse on inspiration. Feels a bit short of breath.
    • New cough, no haemoptysis, no sputum
    • PMHx: Nil Now you mention it
    • Meds: microgynon, NKDA her calf really does
    hurt and has for a
    • Travel history: came back from Australia last week few days
    • FHx: nil
    • SHx: smoker 10/day, drinks 20Units/ week

    • O/E: HR 103, BP 130/89, T36.7, spO2 98% L calf very painful, red hot and swollen
    Differentials Investigations
    • PE • Bloods
    • Pneumonia • FBC, CRP, UE, LFT, troponin
    • Calculate her Wells score
    • Pneumothorax • ?D-dimer or CTPA
    • Costochrondritis • ABG
    • MI • CXR
    • ECG
    What does this ECG show?
    CTPA
    • If CTPA cannot be carried out immediately –
    ANTICOAGULATE
    • Monitor in case they become
    haemodynamically unstable

    PE • PESI score; prognostic stratification

    management • CTPA has confirmed presence of a PE


    • Treatment dose apixaban for PE 10mg BD 7
    days then 5mg BD maintenance
    • Anticoagulant education and alert cards
    • Follow up in clinic
    Massive PE
    • Sustained hypotension (systolic <90) requiring inotrope support,
    pulseless or persistent profound bradycardia

    • Thrombolysis first line if cardiac arrest is imminent


    • 50mg alteplase bolus

    • Thrombus fragmentation and IVC filters


    • 60M, walks into A&E with • O/E:
    Case 3 sudden onset SOB and chest
    pain, stabbing, worse on • HR95, RR27, BP155/90,
    inspiration spO2 92%
    • No fevers, no haemoptysis, • Alert
    dry cough (ongoing 6months),
    weight loss, night sweats
    • No recent travel • General inspection pt looks
    SOB
    • PMHx; HTN, nil else
    • Finger clubbing
    • Meds; ramipril NKDA
    • On examination of the chest
    • FHx: nil – reduced chest expansion,
    reduced breath sounds and
    Hyperresonance on R side.
    • SHx: smoker 50 pack years,
    drinks 30U/week, lives at
    home alone, retired bus driver
    Differentials Investigations
    • Pneumothorax • Immediately treat?
    • Primary • CXR
    • Secondary
    • Tension
    • ECG
    • Pneumonia • Bloods
    • FBC, UE, CRP, LFT
    • PE
    • MI
    Aspiration with 16G cannula Surgical chest drain
    Others
    MCQs
    What does this ABG show?
    a. Type 2 respiratory failure • pH: 7.3 (7.35-7.45)
    b. Type 1 respiratory failure • paO2: 6.8 (7.5-10)
    c. Respiratory acidosis • paCO2: 8 (3.5-4.5)
    d. Metabolic acidosis
    • HCO3: 32 (22-28)
    A. TYPE 2 RESPIRATORY
    FAILURE
    - acidotic, hypoxic, CO2 retainer,
    chronic changes
    a. Bordered by pectoralis minor,
    6th intercostal space and
    serratus anterior
    b. 2nd intercostal space,
    Where is the midclavicular line
    triangle of c. 5th intercostal space mid
    axilliary line
    safety d. Bordered by axilla, pectoralis
    major, latissimus dorsi and 5th
    intercostal space
    Where is the triangle
    of safety

    d. Bordered by axilla,
    pectoralis major, latissimus
    dorsi and 5th intercostal space
    What is this
    diagnosis?
    a. Pneumonia
    b. COVID19
    c. Pulmonary oedema
    d. Pneumothorax
    What is this
    diagnosis?
    a. Pneumonia

    b.COVID19
    c. Pulmonary oedema
    d. Pneumothorax
    COVID19 management *currently*
    • Symptoms: cough, SOB, loss of taste and smell, diarrhoea, vomiting, feeling
    generally unwell, off legs  EVERYTHING

    • Diagnosis: swabs, CXR, bloods (typically high neutrophils and low lymphocytes)

    • Management: dependent on risk category


    • Oxygen
    • Dexamethasone 6mg
    • Antibiotics; co-amoxiclav/ doxycycline
    • Remdesivir vs Tocilizumab?
    • For or not for escalation – NIV…
    a. Sinus bradycardia
    What is the
    ‘textbook b. S3T1Q3
    finding’ for
    PE on c. S1Q3T3
    ECG?
    d. Pleural rub
    What is the ‘textbook finding’ for PE on ECG
    C. S1Q3T3
    • Asthma facts and statistics | Asthma UK
    • BTS_SIGN Asthma Guideline Quick Reference G
    uide 2016.pdf
    • Advanced Management Options for Massive a
    nd
    Submassive
    Extra Pulmonary Embolism | USC Journal
    • British Thoracic Society guidelines for the man
    reading and agement of suspected acute pulmonary emboli
    sm | Thorax (bmj.com)
    references • Pneumothorax | Acute Management | ABCDE
    | Geeky Medics
    • Pneumothorax – AMBOSS
    • Covid-19 controversies: the tocilizumab chapte
    r | The BMJ
    • COVID-19: Dexamethasone in adults (nice.org.
    uk)
    Thank you
    Any questions?

    [email protected]
    Pulmonary oedema

    • Sit patient upright


    • 100% O2
    • IV morphine – helps anxiety with
    breathing, if already exhausted- avoid
    • Antiemetic
    • Furosemide 50mg IV, repeat 30mins-
    1hour (can double dose when repeating)
    • GTN
    • CPAP, NIV
    • Critical care review - ?inotropes, invasive
    ventilation

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