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IPE Insight Cardio Resp

Lecture 2012
by

Aishwarya Desai

on 19 February 2016

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Transcript of IPE Insight Cardio Resp

Cardio-Respiratory
Aishwarya Desai
leicesterinsight@hotmail.com

www.leicesterinsight.com

Hypertension
Heart Failure
Infection / Inflammation
Infections
Emergencies
COPD
There's no time!
The cardiac output it insufficient to meet the body's demand
Chronic Obstructive Pulmonary Disease
- Asthma
- Pulmonary fibrosis
- CF, Bronchiectasis
- Lung cancer, mesothelioma
- Pulmonary HTN
- CXR, Lung function
- Respiratory failure
- Sarcoidosis
Cardiology
Respiratory
- COPD
- Pneumonia
- TB
- Pneumothorax
- Pleural Effusions
- Pulmonary Embolism
- Asthma
- Pulmonary fibrosis
- CF
- Bronchiectasis
- Lung cancer, Mesothelioma
- Cor pulmonarle
- CXR, Lung function
- Respiratory failure
- Valvular heart disease
- Pericarditis
- Infective endocarditis
- Heart Failure
- Ischaemic heart disease
- Arrhythmias
- Atrial myxoma
- Hypertension
- ECG
- Cardiac drugs
Pneumonia
Tuberculosis
An infection of the lung parenchyma characterised by consolidation on a chest radiograph
Classification
Community
Hospital
Aspiration
Immunocompromised
- Streptococcus pneumonia
- Haemophilus influenzae
- Mycoplasma pneumonia

- Legionella pneumophilia
- Chlamydia pneumophilia
- Staphylococcus aureus
- Enterobacteria
- Staphylococcus aureus
Stroke, decreased consciousness, bulbar palsies, oesophageal disease
- Any bacteria
- Pneumocystis jiroveci (P. carinii)
- Mycobacteria
- Fungi - aspergillioma
- Viruses - CMV, HSV
Clinical Features
Symptoms - cough, fever, malaise, dysponea, sputum production, pleuritic chest pain
Signs:
- Tachycardia, tachypnoea
- Decreased chest expansion
- Dullness on percussion
- Increased vocal fremitus
If pleural effusion - pleural rub
Investigations
- Bloods
- CXR
- ABG
- Sputum culture
- Blood culture
(Serology, BAL, pleural aspirate
Management
Complications
Septicaemia, empyema, lung abscess, pleural effusion
1. Analgesia

Paracetamol for pleuritic chest pain
2. Oxygen
Aim for sats: 88% - 92%
>92%
3. IV fluids
4. Antibiotics
Amoxicillin / Doxycycline
IV Co-amoxiclav
Wait for microbiology MC&S
Ethnic background, recent foreign travel
- Productive cough with haemoptysis
- Contact tracing
- Histology = caseating granuloma

Caused by mycobacterium tuberculosis
Acid fast - 3 sputum samples
Zeihl Neelsen staining
Management
- Similar investigations as prior
- Before treatment
- Chech LFTs, U&E, FBC
- Colour vision, acuity
Treatment
- Rifampicin
- Isoniazid
(Pyridoxine)
- Pyrazinamide
- Ethambutol
- Arrhythmias
SVT / VT
- Atrial myoxma
- IHD
STEMI. NSTMEI. ACS
- ECGs
- Drugs
Pneumothorax
Pleural Effusion
Pulmonary Enbolism
The accumulation of fluid within the pleural space.
Transudate
Exudate
<30g/dl
>30g/dl
pneumonia, malignancy
TB, PE
heart failure, liver cirrhosis
nephrotic syndrome
hypoalbuminaemia
Management
- US guided thoracocentesis
- Fluid sent for: pH, MC&S, LDH, protein
- Treat cause
Clinical Features
- Breathlessness

- Tracheal deviation, stony dull percussion, decreased breath sounds, decreased chest expansion
Risk factors - pregnany, OCP, malignancy, air travel, immobility, post op - Well's Score
Clinical features:
- Dyspnoea, tachypnoea, haemoptysis
pleuritic chest pain
- Tachycardia, clinical DVT, elevated JVP
Bloods:
- ABG, Clotting, d-dimer
ECG:
- Tachycardia
- S1Q3T3
Imaging: CTPA; V/Qscans
- Doppler USS
Management
- Analgaesia
- Maintain oxygen sats
- Anticoagulation: LMWH, Warfarin
Primary
Secondary
Tension
Spontaneous
Young men
Pleural blebs
(foci of weakness)
Pre-existing lung disease
Cyst from COPD
Life threatening
- One way valve
Rising pleural pressure
- Ventilation & circulation compromised
- Absent chest sounds, deviated trachea (AWAY), dyspnoea, hyper-resonance

Clinical diagnosis
- Cannula > 2nd ICS, MCL
- Chest drain

- No CXR.
Emphysema
Abnormal permanent dilatation of airspaces distal to the terminal bronchiole.
Radiological diagnosis
Chronic bronchitis
Productive cough for 2-3 months for 2 years
Clinical diagnosis
COPD - FEV1
Mild
>80
Moderate
50-79
Severe
<50
Clinical Features
Symptoms: Cough (productive), wheeze, dysponea

Signs: Tachypnoea, hyperinflation

Complications:
- Infective acute exacerbations
- Respiratory failure
- Cor pulmonare
- Pneumothorax
Acute Exacerbation
- Oxygen (Type II resp failure)
Hypoxia kills
- Nebulized bronchodilators
- Steroids
- ABX
(No response = repeat nebs, NIPPV)
Think about escalation (pts who warrant therapy)
Chronic Management
1. Assessment: Spirometry, ABG

Non pharmacological: smoking, exercise, weight loss

Pharmo: Mild - Antimuscarinic inhaler
Moderate - Regular ipratropium / LABA, inhaled steroids, oral theophylline
Severe - Combination with SABA, REFER to specialist, steroid trial, LTOT
Pericarditis
Infective Endocarditis
Infection of endothelium

Vegetations = Bacteria + fibrin + platelets

Normal valve > acute endocarditis
Prosthetic valves > subacute

Bacteraemia increases chance of infection
- Dentistry, IV cannulation, surgery, etc.

Streptococcus viridans is the commonest cause, Staphylococcus aureus
Clinical Features
Sepsis - fevers, rigors, malaise, clubbing
NEW / change in murmur
(Osler's nodes, Janeway lesions)

Emboli - stroke, haematuria, ARF, (flea bitten kidney), limb, bowel ischaemia

VAGUE Symptoms
Duke Criteria
2 major / 1 major + 3 minor / 5 minor
Major
- Typical organism in 3 different blood cultures
- ECHO - POS for vegetations
Minor
- Fever >38
- IVDU
- Pos blood cultures with atypical bacteria
- Vascular / imm signs
- Atypical echo findings
Management
1. Microbiology

2. Senior cardiology review

3. Empirical therapy:
- BenPen
- IV Gent
Sharp, stabbing - central, radiates to shoulders
Worse lying down
Assoc: constitutional symptoms
Viral, post MI (Dressler's),
Uraemia
Primary
Secondary
95% of all cases
Unknown origin

Common incidental finding in GP
- Examine CVS, renal disease, eyes > Retinopathy
Malignant
- 5% of all cases
- Renal: renovascular disease, intrinsic renal disease
- Endocrine: Cushings, Conns, HyperPTH
- Pregnancy
I - Thicken arteries (silver wiring)

II - AV nipping

III - Cotton wool spots

IV - Papilloedema
Blood Pressure: 200mmHg systolic / 130mmHg diastolic
+ bilateral retinal haemorrhages

- Headache +/- visual problems

- Bloods: U&E - severe hyponatraemia
(hypertonic saline VERY CAREFUL MONITORING ITU)
- Arterial Line

Fibrinoid necrosis
-
degenerated collagen, eosinophilic deposits found within the blood vessel walls

Aim to reduce BP over days (cerebral autoregulation > increased stroke risk) -
IV labetolol /
Na Nitroprusside
Anti-hypertensives
Aim for BP <140/85mmHg
<130/80 in diabetics
<125/75 with proteinuria

Drugs: ACE inhibitors, Calcium channel antagonists, B blockers, Diuretics
Right Sided Heart Failure
Left Sided Heart Failure
Acute Pulmonary Oedema
Causes
Chest Radiograph
Pump Failure
Excessive Preload (dBP)
- Mitral regurgitation
Excessive Afterload
(Pressure against which the ventricle ejects blood)
- AS
- Hypertension
CO = HR x SV
Heart Rate
- Heart block
- MI
Stroke Volume
Can't fill
- Pericarditis
- Tamponade
Can't pump
- IHD
- Cardiomyopathy
Symptoms:
- Poor exercise tolerance; dyspnoea, PND, cough (frothy), orthopnoea

Signs:
- Tachycardia, pulsus alternans, displaced apex, bibasal end expiratory crackles
- Signs of pleural effusion
Symptoms:
- Peripheral oedema, ascites, nausea

Signs:
- Tachycardia, tachypnoea, pulsus alternans
- RV heave
- Elevated JVP
- Pitting oedema
- Hepatosplenomegaly
Investigations
- Bloods: U&E, Cardiac enzymes
- CXR
- ECG
- ECHO
(BNP)
Management
Initial
- Sit pt upright, 100% O2
- IV Diamorphine
- IV Furosemide 40mg
- GTN spray
(Further furosemide, CPAP, HELP)
- Measure urine output
- Obs every 15 minutes
Stable
1. Transfer to ward
2. Daily weights
3. Oral furosemide
4. Treat cause
5. Outpatient HF appointment
6. HF nurse
Full transcript