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 - 7.40PO2 - 78PCO2 - 46HCO3 - 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 CSS’s 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 doesn’t 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• Virchow’s 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 :)