Grand Rounds -Respiratory

Adrian Castro

Mrs D.I.
60 y/o female Presents to ED on Monday 26/3 HPI
Sudden onset SOB since Sunday, worse on exertion Coughing + green phlegm Audible wheeze, present since Sunday Chest pain around diaphragm with cough/inspiration Painful calves for past 2 weeks denies fever

Observation and Examination

RR: 28 regular HR: 96 regular BP: 138/68 SpO2: 94% on RA Speaking in words Using accessory muscles JVP not elevated Mild ankle oedema

Differentials?

Differentials
Asthma exacerbation COPD exacerbation Pulmonary Embolism Pneumonia

ED - Initial Management?

Initial Management
Nebulize
Salbutamol Ipravent

IV hydrocortisone IV frusemide IV ceftriaxone and azithromycin GTN patch

Further History?

PMHx
IDDM HTN Cholesterol Osteoarthritis GORD Asthma Emphysema

PMHx
OSA 5 year Hx of orthopnoea sleeps on recliner Mar 2009 - Left renal cancer Aug 2010 right DVT Nov 2011 - Pancreatitis 2nd to gallstones

Medications
Clexane 100mg bd Hydromorphone Jurnista & dilaudid Panadol osteo Pantoprazole Lipitor Atacand Plus

Medications
Ventolin Spiriva Seretide Novarapid Lantus

Social
Ex smoker
Quit 4 years ago Hx of 50/day/30+ years

Lives with husband and son Not completely independent with all ADLs
Needs help showering

Investigations?

Investigations
FBC: unremarkable EUC: high creatinine 111 (0.7-1.4) LFT: high GGT 122 (10-55) ABG:
pH - 7.40 PO2 - 78 PCO2 - 46 HCO3 - 28

Clinical Scoring Systems

Wells Score prediction of DVT
active cancer Calf swelling > 3cm vs other calf Collateral superficial veins Pitting oedema Previous DVT Swelling of entire leg Localized pain along distribution of deep venous system Paralysis, paresis, recent cast immobilization of lower extremities Recently bedridden > 3 days OR major surgery in past 4 weeks Alternative diagnosis at least as likely

Clinical Scoring Systems

Geneva Score - prediction of PE
Age Previous DVT or PE Recent surgery within 4 weeks HR PCO2 PO2 CXR findings

Investigations
D-Dimer
used when CSSs show low to moderate risk *not a diagnostic test but a test for exclusion Negative value indicates low likelihood of venous thromboembolism Positive value does not rule out DVT/PE because there are many other causes of thrombosis
i.e. Liver disease, infection, malignancy, trauma, pregnancy

Investigations
CTPA
Appearance suggestive of several small pulmonary emboli in relation to 2nd/3rd order vessels involving: - L upper and lower lobes - R middle lobe

LL Venous Doppler U/S

Both R and L thigh/calf showed normal blood flow and no thrombi present

Treatment
Anticoagulation
Clexane
dose increased to 120mg bd on haematologist recommendation Check therapeutic level with Anti factor Xa level

Warfarin
Peak effect doesnt occur until 36-72hrs after Check therapeutic level with INR (2-3)

*ensure empirical anticoagulation therapy in ALL patients suspected of having a DVT or PE

Treatment
Thrombolysis
Indicated when patient shows signs of haemodynamic instability Suggested for non-hypotensive, high-risk patients who have a low risk of bleeding
*PE severity vs prognosis vs risk of bleeding to decide whether to commence thrombolytic therapy

Risk Factors
Virchows Triad Hereditary
Protein C/S, Plasmin, Anti-thrombin III, fibrinogen

Recent Surgery Trauma Immobilization Pregnancy Infection Malignancy OCP and HRT

Fun Facts (yay)

Can arise from anywhere in the body, most often from calf veins
Thrombi predominantly originate in venous valve pockets + other sites of stasis

Fun Facts (yay)

Major sudden cause of death 2nd only to sudden cardiac death Empirical anticoagulation therapy decreases mortality rates from 30% to <10% Lower lobes are more often involved Pleuritic chest pain associated with smaller emboli

Thank you :)