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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_2935_Библиотеки_им_академика_М_И_Перельмана
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Respiratory Emergencies246
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• Hypoxia.
• Tachycardia.
• Pale.
• Clammy.
• Poor capillary refill.
• Hypotension, including postural drop >20 mmHg SBP.
• Gallop rhythm.
• Incre ase d JV P.
Laboratory features:
•
• Elevated serum troponin
• Raised serum lactate
CTPA radiological features:
•
• Extensive thrombus burden within main lobar branches.
• Straightening of interventricular septum.
• Enlarged right ventricle.
Consider risk factors (see Chapter 7: Pulmonary Embolism).
•
3. IMMEDIATE MANAGEMENT
e major risk of thrombolysis is bleeding, including intracranial bleeds.
•
MICRO-facts
Contraindications to systemic thrombolysis
Absolute:
•
Ischaemic stroke in last 6 months.
•
Haemorrhagic stroke at any time.
•
GI bleeding in last month.
•
Known bleeding.
•
CNS neoplasm.
•
Relative:
•
TIA in last 6 months.
•
Malignancy.
•
Oral anticoagulation.
•
Pregnancy or within 1 week post-partum.
•
Non-compressible punctures.
•
Traumatic resuscitation.
•
Advanced liver disease.
•
Infective endocarditis.
•
Active peptic ulcer.
•
Respiratory Medicine
16.6 Massive Pulmonary Embolus (PE)
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Immediate management of massive PE is summarised as a flowchart in
•
Figure 16.5.
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Figure 16.5 Management of massive PE.
Respiratory Medicine
Respiratory Emergencies248
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16.7 MASSIVE HAEMOPTYSIS
1. DEFINITION
Haemoptysis is the coughing of blood originating in the respiratory tract
•
below the larynx.
A number of thresholds for “massive” haemoptysis have been proposed.
•
ese range from 100 to 600mL lost in 24 hours.
•
e risk of death is from respiratory compromise, rather than hypovolaemia
•
or shock.
2. AETIOLOGY
Typically the bleed arises from the bronchial circulation, which is a higher
•
pressure system than the pulmonary circulation.
Bleeds from the pulmonary circulation can arise from arteriovenous (AV)
•
malformations.
Specific causes:
•
• Tuberculosis (Rasmussen’s aneurysm)
• Bronchiectasis
• Lung abscess
• Aspergillosis
• Cystic fibrosis
• Neoplasia
• Pulmonary embolism
• Vasculitis
• Trauma:
– Pulmonary artery catheter
– Penetrating external
– Blunt external.
• Arteriovenous malformation
• Cardiac valve disease:
– Mitral stenosis
– Infective endocarditis.
• Coagulopathy.
3. MANAGEMENT
Massive haemoptysis is a medical emergency.
•
Immediate management:
•
• Resuscitate according to “ABC” approach.
– Position the patient on the affected side if the bleeding point is
known – this will allow a tamponade effect.
Respiratory Medicine
– High-flow oxygen and suction.
16.8 Superior Vena Cava Obstruction (SVCO)
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– Secure the airway: may require intubation with a double lumen
tube.
◯
An anaesthetist with suitable expertise may able to attempt tamponade with a Foley catheter via the endotracheal tube.
– Transfuse based on haemodynamic parameters, not blood lost.
• Reverse any coagulopathy or thrombocytopenia, stop antiplatelet and
anticoagulant drugs.
• Tranexamic acid is effective (can be given IV/PO or nebulised).
• Localise the bleeding site.
– CXR followed by CT with contrast.
– Bronchoscopy.
• Angiography and embolisation: embolisation of the bronchial artery.
– Usually considered if initial management fails to control the bleed-
ing, or if there is a high risk of rebleeding.
– Used in AV malformations as a definitive treatment or before sur-
gery can be performed.
– Small risk of spinal cord infarction.
• Bronchoscopic therapy:
– Iced saline lavage: causes vasospasm.
– Topical agent s: adrenaline, thrombin or fibrinogen-thrombin glue.
– Endobronchial balloon catheter tamponade.
– Laser photocoagulation.
• Surgical management:
– Segmentectomy
– Lobectomy
– Pneumonectomy.
• Radiotherapy:
– If malignancy is the underlying cause.
249
16.8 SUPERIOR VENA CAVA OBSTRUCTION
(SVCO)
1. AETIOLOGY
Superior vena cava obstruction (SVCO) occurs due to an intrinsic obstruc-
•
tion or extrinsic pressure on the SVC wall.
Can be supra- or infra-azygous.
•
• Infra-azygous is more severe.
Specific causes:
•
• Primary bronchial carcinoma: the most common cause (~75% of
malignant SVC cases).
• Lymphoma: ~12% of malignant SVC cases.
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Respiratory Emergencies250
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• ymoma.
• Germ cell tumours.
• Metastatic disease.
• Aortic aneurysm.
• Mediastinal fibrosis:
• Infections
• Radiotherapy.
• SVC thrombosis:
• Central venous catheter.
• Pacemaker or implantable cardiac defibrillator leads.
2. CLINICAL FEATURES
Plethoric.
•
Swollen face.
•
Dilated chest collateral vessels.
•
Arm swelling.
•
↑JVP – non-pulsatile.
•
Dyspnoea.
•
Papilloedema.
•
Pemberton’s test: lift arms above head for >1 min; a positive result is devel-
•
opment of facial plethora or cyanosis.
3. INVESTIGATIONS
Chest X-ray: widened mediastinum or mass in right hemithorax.
•
CT scan: with contrast.
•
Doppler scan: use to evaluate the severity of obstruction and effect of
•
therapy.
Invasive contrast venography.
•
4. MANAGEMENT
Elevate the head.
•
Give oxygen if hypoxic.
•
High-dose dexamethasone (8 mg BD) is usually given with proton pump
•
inhibitor (PPI) cover (although this is often of limited efficacy).
Stenting the SVC is appropriate in SVCO if the patient is very symptomatic,
•
although may be deferred if treatment of the underlying cause is expected to
be successful.
Consider low-molecular-weight heparin (LMWH) to prevent thrombosis.
•
Aim to confirm diagnosis.
•
Treatment of the underlying disease.
•
Respiratory Medicine
• Radiotherapy for most malignancies.
• Urgent chemotherapy if small cell lung cancer.
• Lymphoma should respond to dexamethasone in the short term.
• Anticoagulants for central venous thrombosis.
16.8 Superior Vena Cava Obstruction (SVCO)
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MICRO-case
You are the SHO on nights at a district general hospital when you are
called to see a 75-year-old patient who has become acutely short of
breath over the last few minutes. The staff nurse responsible for the
patient explains that she became acutely short of breath after receiving a
dose of amoxicillin for a presumed pneumonia. She has no documented
history of penicillin allergy and has never been in hospital before. As
this patient has acutely deteriorated, you use the ABCDE approach to
examine her:
A: Patent, patient speaking in short sentences, no evidence of stridor.
B: Dyspnoeic, respiratory rate is 26, wheeze on auscultation.
C: BP – 110/65 (her normal BP is ~140/80). Heart rate – 112 bpm.
D: GCS 15/15. BMs normal.
E: Urticarial rash (wheals) around the cannula site.
You recognise a case of anaphylaxis and begin acute management,
asking a nurse to call the medical emergencies team. While you wait
for them to arrive, you administer high-flow oxygen, insert a large-bore
cannula and administer 0.5 mL of 1:1000 adrenaline via the intramuscular
route. The shortness of breath resolves over a few minutes. You prescribe 500 mL normal saline. When the medical emergency team arrive,
the patient has stabilised and the medical registrar commends your
management!
Key Points
Always use the ABCDE approach when assessing the acutely unwell
•
patient. You should also use this approach to document your findings
in the notes.
The clinical picture is more relevant in recognising anaphylaxis than a
•
documented allergy or known trigger.
Suspect anaphylaxis if there is a rapid onset of airway, breathing
•
or circulatory problems associated with skin or mucosal changes.
Always interpret vital signs in the context of the patient’s normal
•
values.
In this case a systolic BP of 110 may have been falsely reassuring
•
if the previous trend had not been noted.
It is better to call the medical emergency team early in a potentially
•
life-threatening situation! The aim is to prevent, as well as manage,
cardiac arrest.
251
Respiratory Medicine
17
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Smoking and the
Lung
1. EPIDEMIOLOGY
In the UK the number of people who smoke is decreasing, however a signifi-
•
cant proportion of people still smoke.
• In 2021, 13% of UK adults smoked which equates to an estimated
7 million UK adult cigarette smokers (see MICRO-References, below)
• Two thirds of smokers start before the age of 18.
• Smoking rates are higher in lower socio-economic groups.
MICRO-references
www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/
healthandlifeexpectancies/bulletins/adultsmokinghabitsin
greatbritain/2021
2. COST TO THE NHS
Smoking costs the NHS in England an estimated £.26billion a year.
•
In 2015/16, £145 million was spent on prescriptions to help stop smoking.
•
In 2015/16, 520, 000 hospital admissions were directly attributable to
•
smoking.
MICRO-reference
www.gov.uk/government/publications/cost-of-smoking-to-the-nhs-inengland-2015/cost-of-smoking-to-the-nhs-in-england-2015
DOI: 10.1201/9781315113937-18
3. MORTALITY
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Smoking is the largest cause of preventable and premature death in the UK,
•
and is greater than all the next 6 causes put together.
• ere are 100, 000 deaths a year in the UK due to smoking, and 6 mil-
lion deaths a year globally.
• Roughly 50% of smokers will die of smoking-related illness.
After the age of 35, every year of smoking reduces life expectancy by
•
3 months.
On average, smokers die 10 years earlier than non-smokers.
•
4. LUNG DISEASE ASSOCIATED WITH SMOKING
Smoking causes 36% of all respiratory deaths; it is implicated in the follow-
•
ing respiratory illnesses:
• Lung cancer
– 80% of lung cancer deaths are attributable to smoking.
• COPD
– Smoking accounts for 90% of COPD cases, and 30- 40% of
smokers develop COPD.
– Patients who continue to smoke have a greater rate of lung function
decline and poorer outcomes.
• Pneumonia
– ere is higher risk in both passive and active smokers.
• TB
– Smoking is a risk factor for developing TB. Furthermore, smokers
with TB have a higher mortality rate.
• Asthma.
– Exacerbates asthma symptoms, causing higher rates of
hospitalisation.
– Reduces the effectiveness of inhaled corticosteroids.
– Exposure to secondhand smoke is a trigger for the development of
childhood asthma and leads to increased symptomatology.
5. EXTRA-PULMONARY DISEASE
253Smoking and the Lung
Respiratory Medicine
Smoking is implicated in cancers other than lung including oral, bladder,
•
breast, renal, gastric, liver and cervical cancers.
e extra-pulmonary health effects of smoking are listed in Table 17.1.
•
Smoking and the Lung254
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Table 17.1 Extra-pulmonary health effects of smoking.
EXTRA-PULMONARY
ORGAN SYSTEMS DISEASES DIRECTLY ATTRIBUTABLE TO OR
EFFECTED BY SMOKING STRONGLY ASSOCIATED WITH SMOKING
Cardiovascular disease • Chronic heart disease.
• Myocardial infarction.
• Angina pectoralis.
• Peripheral vascular disease.
• 17% of all cardiovascular disease deaths are
attributable to smoking.
• Increased risk of abdominal aortic aneurysm
and rupture.
Cerebrovascular disease • 10% of deaths from stroke are attributable to
smoking.
• Increased risk of intracranial aneurysm.
Gastrointestinal disease • Gastric cancer.
• Duodenal and gastric ulcers.
• Colonic polyps.
• Crohn’s disease.
Oropharyngeal disease • Poor dentition.
• Head and neck cancers.
Eye disease • Cataracts.
• Macular degeneration.
• Optic neuropathy.
Reproductive organs • Impaired female fertility.
• Earlier onset of menopause.
• Increased rates of cervical and breast cancer.
• Reduced sperm count and increased rate of
impotence.
• Neonatal complications:
• Premature birth.
• Low birth weight.
• Preterm related death.
• Sudden infant death syndrome.
6. BRIEF INTERVENTION
Two-thirds of smokers want to stop smoking.
•
Brief interventions allow health care professionals to give opportunistic
•
advice to smokers in a 5–10 minute consultation.
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Smoking and the Lung
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• Brief interventions are evidence based and cost-effective.
• Brief intervention alone leads to 5% of smokers stopping smoking for 6
months.
Multiple interventions have a “dripping tap” effect of encouraging patients to
•
quit over a long period of time
e number needed to treat for brief intervention to prevent one premature
•
death is 80, rising to 16- 40 when behavioural support is added. is compares extremely favourably with commonly prescribed preventative medications for other major health problems.
It should consist of 5 elements as presented in Figure 17.1:
•
255
Figure 17.1 Smoking cessation pathway.
Respiratory Medicine
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