Download Respiratory SAQ`s

Resp SAQs
A 5 year old boy presents with an acute exacerbation of asthma. On
examination there is reduced air entry bilaterally with expiratory wheeze.
He has tracheal tug, sub costal recession and is tachypnoeic. Initial pulse
oximetry reveals oxygen saturation of 85% on room air. He has had no
treatment prior to arriving in the emergency department.
Question
Describe your management of this patient
(100
%)
Answer
Answer and Interpretation
FACEM SAQ Exam 2011.1 – Question 8
(d)
The overall pass rate for this question was 53/81 (65.4%)
A 24 year old woman presents with a left sided spontaneous
pneumothorax.
Question
Discuss the treatment options for her
pneumothorax
(100
%)
Answer
Answer and Interpretation
FACEM SAQ Exam 2011.1 – Question 1
(di)
The overall pass rate for this question was 72/81 (88.9%)
(dii)
Pass Criteria
1.
Candidates must explain/mention that treatment depends
on
1.
Size of pneumothorax
2.
Primary vs. Secondary (i.e. pre-morbid lung
condition)
3.
Whether patient has symptoms
2.
Candidates should describe insertion point
3.
Must decompress unstable patient immediately
4.
Must discuss at least 4 techniques adequately
5.
Must not claim that any technique allows for the discharge
of a secondary pneumothorax
(diii)
Features of unsuccessful answers
Failing answers will not address one or more of the 5 points
made above.
A 22 year old woman with a past history of asthma, presents with a
spontaneous right pneumothorax estimated to be around 25% of lung
volume.
Question
Discuss your management options in this patient.
Answer
Answer and Interpretation
FACEM SAQ Exam 2007.1 – Question 2
(div)
The overall pass rate for this question was 41/55 (74.5%).
(dv)
1.
(dvi)
Pass Criteria
Overall, the examiners considered that this was a good
question which was poorly answered by a significant number of
candidates.
Features of unsuccessful answers
Candidates who performed poorly in this question did not
emphasise the concurrent presence of asthma in the patient, incorrectly
sized a pneumothorax as small and failed to identify the correct site of
intercostal catheter insertion.
SAQ 332
A 27 year old female presents with an acute exacerbation of her asthma.
Her observations are:
GCS 15
Temperature 37.2 degrees Celsius
HR 145
BP 105/60
RR 32
SaO2 88% on 15 l/min O2 via non-rebreathing mask
a) Outline how you would assess the clinical severity of her acute asthma. (30%)
b) Describe your management of this patient including reference to potential intubation and ongoing
ventilation. (70%)
(a) ASSESSING CLINICAL FEATURES OF SEVERITY
History
•
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Multiple previous admissions.
Previous ventilation for same.
Attacks refractory to treatment.
Steroid dependence.
Delayed presentation with maximal therapy at home.
Concurrent smoking.
Co-existing lung disease.
Examination
Increased respiratory effort
• Tachypnoea
• Accessory muscle use.
• Not able to speak normally.
Signs of hyperinflation
• I.e. small tidal volumes with splinted breathing.
• Pulsus paradoxus of more than 10mmHg.
Signs of pulmonary failure
• Cyanosis
• Obtundation / ALOC
• Systemic features of shock with hypotension and tachycardia.
• Dilated pupils.
Investigations
Spirometry / peak expiratory flow rate (PEFR)
• Unable to perform spirometry or PEFR.
• Unable to blow 40% of predicted or previous best.(British Thoracic Society)
CXR
• Signs of hyperinflation.
• Complications such as tension pneumothorax.
ABG
• Normo-carbia or CO2 retention.
• Hypoxia.
• Concurrent metabolic acidosis.
Ventilator features
• Airway pressures in excess of 20 cm water.
• Patient feels stiff to bag with hand held device.
(b) MANAGEMENT OF ACUTE EXACERBATION OF ASTHMA
Environment
• Resuscitation bay with facilities for intubation.
• Non-invasive monitoring including continuous sats.
• Supplemental high flow oxygen.
• Adequate nursing and medical staff.
• IV access secured.
Definitive management
• Continuous nebulised salbutamol in increments of 5 mg each.
• Intravenous salbutamol as a slow push, 10 micrograms per kilogram.
• Ipratropium bromide (Atrovent) 0.5 mg nebulised once.
• MgSO4 nebuliser (local protocols)
• Consider a magnesium bolus of 10 mmol IV.
• Adrenaline nebulised or IV not superior to the above.
• May be used where salbutamol not available.
• Hydrocortisone 200 mg IV.
• Theophylline has little to offer those not suffering from COAD, may precipitate an arrhythmia, and is not to
be recommended.
• Correct electrolyte problems i.e. hypokalemia.
• Look for and treat complications, i.e. pneumothorax.
Supportive management
• The most vexing issue is that of intubation for ventilatory support.
• Indicated where ventilation or gas exchange fails, i.e., respiratory fatigue with obtundation and / or
worsening hypercapnia after a trial of NIPPV.
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•
•
•
•
•
•
•
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Optimal pre-oxygenation.
Fluid load
Suxamethonium 1.5 mg / kg IV.
Ketamine 1 mg / kg IV, unless contra-indications.
Employ a rapid sequence intubation technique with direct laryngoscopy.
As large an ETT as possible, secured.
Vecuronium after successful intubation, 0.1 mg / kg IV.
Morphine and midazolam infusion for sedation.
Ventilate to lesser tidal volume if required, 5 to 7 ml per kg.
Note the concept of permissive hypercapnia.
Set as long an expiratory time as possible for rate.
RR ~ 6
Modest PEEP of 2.5 to 5 cm water if tolerated.
Also place a NGT and IDC.
Consider arterial and central lines.
Maintenance fluids IV, i.e. dextrose saline at 100 ml/h.
Disposition
• Where intubated, admit to ICU.
• Where not, ICU or a respiratory unit HDU.
• In our time of access block, continue a stay in resuscitation bay or transfer to another hospital.
Also see Kool Skool by Franco
1. A 16 month old year old child is brought to your ED by his frantic parents with acute severe
respiratory distress. He had been playing with his older siblings Lego at the time when it began 20
minutes previously.
He is alert , but very distressed with marked tachypnoea and work of breathing.
HR
160/min
BP
95\50 mmHg
Temperature
37
O2 saturation
94% (air)
(a) Outline your investigations
Describe your management.
(30%)
(70%)
SAQ 174
List the history and examination findings which would lead you to classify a patient as having severe
asthma
(Note: old-style question not typical of recent SAQs, but good revision)
Also see SAQ 332
Hx:
• HPC
- Long duration
- Late presentation
- Extreme fatigue
- Failure to respond to optimal home treatment ie maximum bronchodilator doses
• PHx
- multiple previous admissions
- ICU admissions/I&V
- Comorbidities especially those that affect cardiorespiratory reserve (co-existing lung disease eg CF,
pulmonary fibrosis)
• Meds
- Steroid-dependence
• Concurrent smoking
Ex:
• General:
- Upright posture (“tripod”), appearance of exhaustion, cyanosis
- RR >30
- PR > 120
- Sats < 90%
- Speaking in words/nil
- Pulsus paradoxus, Kussmaul’s sign (JVP)
- Obtundation/ALOC
- hemodynamic shock
• Chest:
- Use of accessory muscles: tracheal tug, intercostal and subcostal recession
- little/no chest expansion
- little/no air entry
- lack of wheeze may be indicator of no air movement
• Bedside tests:
-PEFR <40% predicted or unable to perform
-PO2 – hypoxaemia
-PCO2 - normal or rising CO2
-Concurrent metabolic acidosis
• Deterioration despite optimal Rx including NIPPV
A 55-year-old female presents to your Emergency Department with a one-week history of intermittent
haemoptysis.
(a) Outline your assessment of this patient. (80%)
(b) Outline your disposition of this patient. (20%)
ISSUES
1) Quantify amount:
Massive hemoptysis >600ml/24h
Exsanguinating hemoptysis > 1000ml total or > 150ml/hr
2) Wide differential diagnosis:
• Infection – bronchitis or pneumonia, also consider tuberculosis. (Bacterial, atypical, fungal).
BRONCHIECTASIS
• Neoplastic – primary or secondary, ca esophagus
• Vascular - Pulmonary embolism with lung infarct, AVmalformation, pulmonary edema, thoracic aortic
aneurysm
• Connective tissue disease – SLE, Goodpasture’s, Wegener’s, sarcoidosis, collagen vascular disease
• Vasculitis
• Congenital – CF (unlikely in this age group_
• Other – trauma, FB
• Underlying contributors - Coagulation disorder (anticoagulants, antiplatelets, alcoholism/liver disease),
immunocompromise (HIV, steroids)
(a) Assessment:
Aims:
- quantify hemoptysis
- look for cause + contributors
- look for complications
History:
• General historical features of haemoptysis – determine severity of haemoptysis:
o Frequency
o Volumes lost
o Description of blood – fresh v altered
o Ensure not from GIT or nose – non-pulmonary source
• Symptoms of complications of haemoptysis – anaemia:
o Lightheaded, fatigue, pre-syncopal, SOB etc
• Symptoms of potential underlying causes:
o Fever, purulent sputum, SOB, associated URTI symptoms – respiratory infection (bacterial, viral etc)
o Cough, night sweats, weight loss – TB
o Weight loss, SOB, symptoms of primary tumour elsewhere (bowel, breast etc) - malignancy
o Spontaneous bleeding form other sites – vasculitis, coagulation disorders
• Risk factors for potential underlying causes:
o Immunocompromised – infection, TB
o Smoking – primary malignancy
o Hx of previous malignancy (bowel, breast) – pulmonary metastases
o Risk factors for PE – immobility, recent surgery etc
o Hx of underlying / chronic lung disease – bronchiectasis
o Travel history, contacts infection, TB
o Hx of connective tissue disease / vasculitis
• Medications:
o Anticoagulants – warfarin
o immunosuppressants
• Smoking, IVDU, alcohol (liver dysfunction)
Examination:
• General systems examination – focused on respiratory system
• General inspection: cachexia, jaundice, pallor
• Vital signs – gas exchange, hemodynamics
o Fever – infection
o Evidence of respiratory distress – HR, RR, SaO2
• Evaluate sputum to confirm haemoptysis
• Examine nose, upper airway for evidence of bleeding site
• Peripheral stigmata of potential underlying cause:
o Clubbing (bronchiectasis)
o lymphadenopathy – malignancy, TB
o Peripheral signs of vasculitis, Connective tissue disease
o stigmata of chronic liver disease
• Respiratory exam – evidence of consolidation, effusions
Investigations:
• Bedside:
o BSL, ECG – baseline
o WTU – haematuria – vasculitis, coagulation disorder
o ABG – assess ventilation, also check Hb
o Spirometry – baseline, assess underlying lung function
• Laboratory:
o FBC – Hb / Raised WCC – infection / Low platelets – clotting disorder
o ELFTS – baseline / evidence of other organ involvement (vasculitis)
o Coagulation profile – baseline / exclude as cause, ?D-dimer
o ESR – raised in malignancy, infection, connective tissues disease, vasculitis
o Sputum M/C/S, AFB and cytology
o BC if > 38.5
• Radiology:
o CXR – evidence of infection / effusions / malignancy / underlying lung disease
o CT chest – to further delineate infection / malignancy etc
o CTPA chest if need to exclude PE
• Other:
o If effusion present – pleurocentesis – fluid for M/C/S and cytology
o ?Bronchoscopy
(b) Disposition:
• Liaised with respiratory team
• Will be dependant on:
i. severity of haemoptysis
ii. whether the underlying cause is identified
iii. whether the patient is compromised by the haemoptysis or its cause
iv. the treatment required
• If cause found - treatment and disposition dependant on requirements of management and treatment
• If cause not identified at this point:
i. If more than mild haemoptysis, patient compromised requiring supportive care, serious / potentially
imminent life threatening cause suspected – then admit
ii. Otherwise – plan to discharge in liaison with respiratory team for early outpatient review +/- bronchoscopy.
To return sooner if condition worsens.
1986
A 24 year old female who is 4 months pregnant persists with recurrence of severe asthma.
Outline the assessment and management of the patient.
1987
Describe the causes, diagnosis and treatment of pulmonary complications in burn patients (in the
first four hours after injury).
1991/1
A 55 year old lady presents with dyspnoea. She is known to have chronic airways limitation and
is on
home oxygen at 2 litres per minute. At examination she is febrile 37.4 degrees Celsius, with a
respiratory rate of 30 breaths per minute. Her pulse rate is 120 beats per minute and blood
pressure
100/70 mm mercury. She is centrally cyanosed, sweaty and auscultation reveals poor air entry
with
widespread coarse crepitations. Outline the:
(a) Initial assessment;
(b) Investigations;
(c) Treatment;
(dvii)
Disposal.
1996/2
Discuss the indications, delivery technique and possible adverse effects of continuous positive
airways pressure delivered by face-mask.
1998/1
Discuss the treatment options for a 75 year old woman who presents with an exacerbation of her
chronic airways limitation. Her arterial blood gases on room air on arrival are:
• pH 7.28
• pCO2 62 mmHg
• O2 52 mmHg
• HCO3 17 mmol/L
• BE 5 oxygen saturation 84%.
1999/2
Discuss the role of Continuous Positive Airway Pressure ventilation in the Emergency
Department.
2002/1
A 65 year old female presents 10 days following coronary artery bypass surgery at your regional
referral hospital. On examination she has a clean median sternotomy wound, P 105, BP 145/90,
RR 24,
SaO2 94% (room air). There is dullness to percussion and reduced breath sounds at the left lung
base.
ECG shows a sinus tachycardia with ST changes present on her pre discharge ECG. CXR shows
a
moderate left pleural effusion.
Outline your assessment and management of this patient. (100%)
2005/2
A 62 year old man with known chronic renal failure presents with respiratory failure, secondary
to
pulmonary oedema. Oxygen saturation is 89% on 100% oxygen utilizing bi-level positive airway
pressure
(BiPAP). His observations are:
● Glasgow Coma Score 14
● Temperature 37.0oC
● Respiratory Rate 32 /min
● Systolic blood pressure 90 mmHg
● Electrocardiograph Rate of 105 /min with a regular broad complex rhythm.
An urgent Potassium level of 8.7 mmol/L (Reference Range: 3.5-4.9 mmol/L) has been recorded.
Discuss rapid sequence induction in this man. (100%)
2006/2
A 55 year old man has just undergone endotracheal intubation for severe asthma. Immediately
post
intubation, his systolic blood pressure falls to 80 mmHg.
a. Outline the causes of post intubation hypotension in this man. (50%)
b. Describe your ventilation strategy for this man. (50%)
2007/1
A 22 year old woman with a past history of asthma, presents with a spontaneous right
pneumothorax
estimated to be around 25% of lung volume.
Discuss your management options in this patient. (100%)
Discuss options for treatment of pneumothorax in the ED.
2008/1
A 58 year old woman presents to the emergency department complaining of a 5 day history of
sore
throat and progressive difficulty in swallowing.
Examination reveals she is febrile with stridor at rest. Oropharyngeal examination does not
reveal an
overt diagnosis.
Describe your management. (100%)
PAEDS RESPIRATORY
1991/2
A six month old infant presents with acute onset of wheezing.
(a) What are the indicators of the severity of respiratory distress?
(b) Describe and discuss your initial treatment regime.
(c) What factors will determine the need for admission? If the infant is discharged, what advice
would
you give to the parents?
1992/1
A 4 year old child presents with an attack of asthma.
(a) Outline the clinical and investigative indicators of severity.
(b) Outline the admission criteria.
(c) If the child has a peak expiratory flow rate of 50 litres per minute (normal value: 100 litres
per
minute), what management plan would you institute?
1997/2
A 6 year old is brought to the Emergency Department, with worsening asthma for the last 4
hours. On
arrival, she is unable to speak, has marked use of accessory muscles, respiratory rate 60/minute,
pulse
rate 160/minute and oxygen saturation of 92% on 6 litres per minute of oxygen.
(a) Discuss the treatment options for this patient.
(b) What are the indications for intubating this patient?.
1999/1
A 10 year old boy presents with an acute exacerbation of asthma. He is a frequent attendee of
your
department. He has required an Intensive Care Unit admission for his asthma within the last 18
months. He has a Pulse Rate 140 beats per minute, Blood Pressure 95/70 mmHg, Temperature
37.9oC,
Respiratory Rate of 40 breaths per minute and an Oxygen Saturation of 95% on 4 litres per
minute of
oxygen.
Describe your assessment and management of this patient.
2001/2
8 week old baby brought to ED after a 4 hour history of increasing breathing difficulty. He has a
4 days
history of increased cough and conjunctivitis for 2 days. He appears mottled and lethargic. His
pulse
rate is 180/min, RR 65/min, temperature 37.9 (PA) and SAO2 unmeasurable due to poor trace.
His
bedside glucose is 5.4 mmol/L..
Outline your assessment and management of this baby.
2004/2
You are working in a large regional emergency department. You receive a telephone call from a
doctor
at a small community hospital two hours away by road. This doctor is a general practitioner with
limited emergency experience. He asks for advice regarding an 18 month old boy who presented
with
fever, pallor and stridor. Despite intramuscular and nebulised steroid the child has severe
respiratory
distress with stridor.
a) Outline your advice to the referring doctor. (50%)
b) Outline the arrangements you would undertake to transfer this child. (50%)
SAQ 7
A mother brings to your emergency department her 4 day old boy with a 24 hour history of poor
feeding and rapid breathing. He also had 2 episodes where he appeared to stop breathing for a few
seconds.
Describe your assessment of this baby. (100%)
The overall pass rate for this question was 46/81 (56.8%).
The markers felt that this was a reasonable question which was largely poorly answered – hence the
relatively low pass rate. Good answers included assessment aimed at a wide differential which
needed to include significant conditions such as sepsis and cardio-pulmonary disease. Poor answers
failed to include an adequate differential or failed to do a focussed history, examination or a septic
workup.
A 12 year old girl with cystic fibrosis presents unwell with a fever and
acute shortness of breath. Her observations are:
A Chest X-ray reveals bilateral patchy consolidation and a 20% left sided
pneumothorax.
Question
Describe your management of this child.
3.
A 2-year-old boy presents with stridor. What is your assessment and management of
this situation.
8.) A 4 year old girl is brought into your department by her parents with a one week history of dry
cough and wheeze following an URTI. Examination reveals a RR rate of 20, pulse rate of 96 and a
saturation of 98% on room air. She has a soft expiratory wheeze but is happily playing with the
department toys. Her brother has asthma requiring frequent admissions. The family have recently
moved to your city.
You make a diagnosis of asthma. Describe your management4~TE
1.) A 72 year old man presents to your tertiary level department with a 3/7 history of increasing SOB and a
change in the colour of his sputum. He has steroid and oxygen dependent COAD. On examination he
has widespread wheeze, severe use of accessory muscles, is unable to speak and is drowsy. His saturation
on 6L/min is 85%.He fails to respond to initial salbutamol treatment via nebuliser and LV infusion.
Outline your management.
2007/2
A 12 year old girl with cystic fibrosis presents unwell with a fever and acute shortness of breath.
Her observations are:
● Temp 38.2oC
● PR 130 per min
● BP 100/60 mmHg
● RR
30 per min
Sat 91% room Air
A Chest X-ray reveals bilateral patchy consolidation and a 20% left sided pneumothorax.
Describe your management of this child. (100%)
● O2
2008/2
A mother brings to your emergency department her 4 day old boy with a 24 hour history of poor
feeding and rapid breathing. He also had 2 episodes where he appeared to stop breathing for a
few
seconds.
Describe your assessment of this baby. (100%)