Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

Severn Foundation Cases Dr Boris Wagner & Dr Oscar Maltby, F2 UnivsSession 5spitals Bristol and Weston NHS 22nd August 2023 Learning Outcomes Chest pain, ECGs, SOB and Chest X-ray interpretation • Learn how to approach and assess patients with chest pain • Have a structured approach to assessing ECGs while on-call • Learn how to approach, assess and manage patients with SOB • Have a structured approach to assessing Chest X-rays on-call • Learn how to interpret NG Tube CXR 22/08/23The Approach to Chest Pain Dr Oscar Maltby FY2, BRIChest Pain: A Broad DDx Cardiac Psychiatric Cardiac Vascular Chest pain MSK Pulmonary GIKey Points in History ● Nature of Pain ○ Onset ○ Central/Lateral ○ Character - sharp, crushing etc. ○ Radiation ○ Worsening/Relieving Factors - ?Pleuritic ● Associated Symptoms ○ Well or Unwell? ○ Nausea/Vomiting ○ SOB ○ Palpitations ○ Anxiety ● PMHx ○ Why are they In Hospital ○ Cardiovascular Risk FactorsKey Points in Examination ● End-of-the-Bedogram ○ Well or Unwell? ○ Look at the patients’ observations/do them if not done ● Focused Cardiovascular/Respiratory Exam ○ Anything focal? ○ Peripheral Pulses/Peripheral Perfusion ● Chest Wall Tenderness ○ Worsened by Movement? ● Examine the Calves ○ Don’t miss a DVTInvestigations ● ECG ○ Ask the nursing staff to do this before you get there if you are concerned ○ Compare to previous ones! ● Troponin ○ If concerned about ACS ○ Often mildly raised in context of intercurrent illness. Don’t send if not concerned! ○ If up, obliged to send repeat to look for dynamic change ● D-Dimer and/or CTPA if concerned about PE ○ D-Dimer often raised in the context of intercurrent illness - but if very raised, can be helpful ○ If PE is your suspected diagnosis then starting treatment dose clexane in a patient without any obvious bleeding risk is unlikely to cause harm ○ If you are worried enough to start treatment, radiology should really be happy to do a CTPAScenario 1 ● 62F on Resp Ward. ATSP at 7pm re Chest Pain ● Admitted with IE COPD. On IV Abx ● Background of Moderate-Severe COPD (4-5 exacerbations/year), Mild CCF with RV Dysfunction, Hypothyroidism, T2DM on Metformin, HTN, CKD 3 ● Questions?Scenario 1Scenario 1 ● The pain started at some point this afternoon, she’s not sure when exactly, got worse in the last hour or so ● Worse when she coughs. Been coughing ++ all day ● More on the left side of her chest. No radiation ● Had some paracetamol which helped a bit, doesn’t want to take any oromorph “it knocks me for 6” ● 5-6/10 ● No nausea, she is SOB but she thinks it’s got a bit better since she’s been on Abx Examination?Scenario 1 ● EWS = 2 for O2 requirement, HR 85, BP 127/77, RR20, T36.8 ● Looks OK from end of bed. On some nasal O2, weaned from 25% Venturi to 4L NC today ● WWP, Good volume peripheral pulse ● HS 1+2+0 ● Bibasal Crepitations L>R ● Pain elicited a bit by coughing/deep breathing ● Some tenderness on palpation of anterior chest wall ● Calves SNT Investigations? Suspected Diagnosis Here? Management?Scenario 1 ● ECG - NSR, No ST changes. Looks similar to admission ECG ● Troponin - if sent - 19 (normal <14). Repeat trop 17 ● Diagnosis = MSK Chest Pain (from coughing) ○ Reassure ○ Simple Analgesia ○ Could consider whether any benefit from eg. carbocisteine/saline nebsScenario 2 ● 62F on Resp Ward. ATSP at 7pm re Chest Pain ● Admitted with IE COPD. On IV Abx ● Background of Moderate-Severe COPD (4-5 exacerbations/year), Mild CCF with RV Dysfunction, Hypothyroidism, T2DM on Metformin, HTN, CKD 3 ● Questions?Scenario 2Scenario 2 ● Pain started late this afternoon ● Central, no particular radiation, “like I’m choking”. No particular exacerbating/relieving factors ● Hasn’t taken any analgesia ● Associated with palpitations and breathlessness. Feels like her heart is racing, this is more predominant than the pain ● Severity - “don’t really know, maybe a 4 or 5” ● Seen by the Consultant today, felt clinically improving but discussed about possibly needing LTOT in the future. Nurses tell you she was a bit upset about this Examination? Anything else to ask?Scenario 2 ● Mum also had COPD and was put on LTOT. She died <1 month after being on LTOT ● She is worried that she is going to die, “I have too much to live for” ● Looks well but a bit tearful ● EWS = 2 for 1L O2 requirement, HR 98, BP 135/83, RR18, Afebrile ● WWP, Good Volume Pulse, HS 1+2+0 ● A few scattered creps on chest exam ● Calves SNT Suspected Diagnosis? Investigations? Management?Scenario 2 ● ECG - Sinus Rhythm, HR 90. Isoelectric ST segments. ● Troponin - 11 ● Diagnosis - Anxiety ● Management ○ Take time to reassure her that her heart tracing is entirely normal, explain that she is not having cardiac event ○ Probe whether she feels symptoms could be related to anxiety ○ Reassure re. clinical improvement ○ If very anxious/pt. wanting MH support consider eg. liaison psychScenario 3 ● 62F on Resp Ward. ATSP at 7pm re Chest Pain ● Admitted with IE COPD. On IV Abx ● Background of Moderate-Severe COPD (4-5 exacerbations/year), Mild CCF with RV Dysfunction, Hypothyroidism, T2DM on Metformin, HTN, CKD 3 ● Questions?Scenario 3Scenario 3 ● Pain started about an hour ago. Fairly sudden onset, thinks it’s getting worse ● Described as heavy, in the middle of the chest. No radiation. Not pleuritic. ● Had some paracetamol, hasn’t helped. Asking for something stronger because nothing else written up ● Feels a bit nauseous with it, hasn’t vomited. Not SOB ● 7/10 presently ● Had some fish and chips for her tea, wondering if it’s really bad reflux. “I never eat that at home” Examination?Scenario 3 ● Looks a bit sweaty ● EWS = 4. HR 105, RR22, BP 110/55, SpO2 96%, T37.0 ● Slightly cool peripheries, radial pulse normal, HS 1+2, sounds a bit tachy but no added sounds that you can hear ● Some scattered creps in the lungs, nil obviously focal, equal AE ● Trachea is central ● Calves SNT Investigations? Suspected Diagnosis?Scenario 3 ● ECG - Evidence of Ischaemic Change most marked in lateral leads - TWI V4/V5/V6/aVL/I/II. Borderline ST Depression V5/V6 ● Troponin - 497 ● Management?Scenario 3 ● Don’t manage this patient alone ● Medical SpR, Cardiology SpR ● ACS Protocol ○ Be aware of where to find this/how to access it at your hospitalScenario 4 ● 62F on Resp Ward. ATSP at 7pm re Chest Pain ● Admitted with IE COPD. On IV Abx ● Background of Moderate-Severe COPD (4-5 exacerbations/year), Mild CCF with RV Dysfunction, Hypothyroidism, T2DM on Metformin, HTN, CKD 3 ● Questions?Scenario 4Scenario 4 ● Pain started about half an hour ago. “Came on out of the blue”. ● Mainly in the right side of her chest ● Sharp, catches her when she breathes in. Had some oromorph, helped a bit ● Nil radiation of note ● 7/10 ● Feels a bit SOB, has been on O2 for her IE COPD. O2 requirement currently 30% Venturi, was 4L NC this afternoon Examination?Scenario 4 ● Looks slightly uncomfortable ● EWS =3, SpO2 95% on 30% O2, HR 114, RR 20, BP 132/77, T37.1 ● WWP, Pulse a bit tachy, HS 1+2+0 ● Right basal crepitations on chest exam ● Pain worse on inspiration ● Calves SNT Next Steps?Scenario 4Scenario 4 ● ECG - Sinus Tachycardia, RBBB (?degree of right heart strain) ● D-Dimer 2752 (<450) ● CTPA - Subsegmental Right Sided Occlusive Thrombus ● Rx Anticoagulation ○ Treatment Dose LMWH - 1mg/kg BD at UHBW ○ UFH in renal impairment eGFR <30 ○ Refer to your own hospital guideline ● If became haemodynamically unstable - would be for consideration of thrombolysis ○ Not an F1 decision!Features of An Ischaemic ECG ● STEMI Criteria Typically Accepted As: ○ ST Elevation >2mm in 2 contiguous chest leads ○ ST Elevation >1mm in 2 contiguous limb leads ○ New/Presumed New LBBB ● Hyperacute T-Waves - can be an early sign of cardiac ischaemia ● ST Depression/T-Wave Inversion ○ Horizontal or downsloping ST Depression >0.5mm at the J point in 2 contiguous leads is indicative of cardiac iscahemia ○ ST Depression >1mm is more specific and conveys a worse prognosis ● Q Waves - typically indicative of an old infarctChanges?Changes?Changes?Changes?Thank You For Listening! Shortness of breath (SOB) / Hypoxia Doctor… “This patient has low saturations” “This patient is having difficulty breathing” “This patient has a high respiratory rate” “Patient is scoring a 3 in one parameter” 22/08/23 Shortness of breath (SOB) / Hypoxia On the phone: 22/08/23 Shortness of breath (SOB) / Hypoxia On the phone: NEWS Score Observation trend? How much Oxygen are they on? Are they known to have airway disease? e.g. COPD, known CO retainer, Scale 2? 2 What are they in hospital for? e.g. pneumonia, on IV ABX vs non-respiratory pathology 22/08/23Shortness of breath (SOB) / Hypoxia On the phone: NEWS Score Observation trend? How much Oxygen are they on? Are they known to have airway disease? e.g. COPD, known CO retainer, Scale 2? 2 What are they in hospital for? e.g. pneumonia, on IV ABX vs non-respiratory pathology Hypoxiais a MedicalEmergency You should consider calling for help early if a patient is rapidly deteriorating Hypoxia – patient assessment Your patient assessment should be approached using A-E system RESPONSIVENESS Unresponsive/drowsy + hypoxic → 2222 call AIRWAY Airway problem → airway manoeuvres, peri-arrest call + adjuncts BREATHING • Ensure the sats probe is giving a good trace otherwise adjust it • Sit the patient upright to improve oxygenation • Inspection, Percussion, Auscultation . Hypoxia – patient assessment Your patient assessment should be approached using A-E system RESPONSIVENESS Unresponsive/drowsy + hypoxic → 2222 call AIRWAY Airway problem → airway manoeuvres, peri-arrest call + adjuncts BREATHING • Ensure the sats probe is giving a good trace otherwise adjust it • Sit the patient upright to improve oxygenation • Inspection, Percussion, Auscultation . Giving 15L/min high flow oxygen whilst you assess and/or seek help gives you time Hypoxia kills before hypercapnia! Hypoxia – patient assessment Look for clues around the bedside IV fluids running/known heart failure with reduced EF –?pulmonary oedema Evidence of swallowing problems e.g. NBM sign/dementia/stroke – ?aspiration Are they on a cardiac monitor? Are they on NIV? • Deteriorating patient, increase the oxygen via NIV to maximum & urgently call for senior help. If well/stable, complete your A to E assessment. If not, initiate treatment before moving on Hypoxia – patient assessment Look for clues around the bedside IV fluids running/known heart failure with reduced EF –?pulmonary oedema Evidence of swallowing problems e.g. NBM sign/dementia/stroke – ?aspiration Are they on a cardiac monitor? Are they on NIV? • Deteriorating patient, increase the oxygen via NIV to maximum & urgently call for senior help. If well/stable, complete your A to E assessment. If not, initiate treatment before moving on Order an ABG & CXR in all newly hypoxic or deteriorating patients →Portable CXR should be considered if unwell →Check RESPECT/Escalation status Chest X-RAYS Commonscenariosto ordera CXR • Any suspicion of acute/chronic lung pathology (cancer, infection, oedema, effusion) • Deteriorating patients • Confirmation of NG tube placement (this should ideally be done within working hours) • Post interventions e.g. central line, chest drain or pacemaker (to rule out pneumothorax) Chest X-RAYS Commonscenariosto ordera CXR • Any suspicion of acute/chronic lung pathology (cancer, infection, oedema, effusion) • Deteriorating patients • Confirmation of NG tube placement (this should ideally be done within working hours) • Post interventions e.g. central line, chest drain or pacemaker (to rule out pneumothorax) 1. Always interpret CXR in clinical context of your patient 2. Change in clinical condition warrants a repeat CXR 3.Handover: always ask: How is the patient? Why? Does it need to be done OOH? Escalation plan depending on findings (ie. which ABX ` to escalate to) Chest X-RAY Interpretation Use a systematic A to E approach to interpreting CXRs Check patient details, time and date of CXR and image quality Airway → Check the trachea is central. Check hilar regions Breathing→ Assess the lung fields. Divide the lungs into 3 zones and inspect the lung markings are present in each zone. Check if each lung is symmetrical with the other. Inspect the pleura as well. Cardiac → In a PA film, assess the cardiothoracic ratio ?cardiomegaly Use the cardiac & diaphragmatic borders to ensure you don’t miss disease processes Diaphragms → Flattening? COPD. Look for free gas under the diaphragm ?perforation Assess the costophrenic angles which might be obscured in pleural effusion (look for a meniscus) or consolidation Everythingelse→ mediastinum, bones, soft tissues & foreign tubes & devicesChest X-RAY Interpretation Always compare to previous imaging available on the system CXR CASES Ward Cover F1 5pm Handover: Jane Doe Bed 26 General Medical Ward 78F patient a/w Urosepsis 5/7 ago Was clinically improving Today, more SOB Please can you chase the CXR? Booked for 6PM 22/08/23Case 1: Pulmonary oedema → Assess patient → Stat IV furosemide 20-40mg → Then reassessCase 2: Pneumothorax → Urgently assess patient → Discuss w senior → Likely to need chest drainCase 3: Right lower zone Pneumonia → Assess patient → Ensure on appropriate ABX → F-U CXR in 6-8 weeks to ensure opacification resolvedCase 4: Pneumoperitoneum → Assess patient → Signs of perforation? → Discuss with surgeons → Likely to need CT → NG tube + IV Abdo sepsis ABXCase 5: Left sided empyema → Asses pt → New change? → Discuss w SpR → Likely to need chest drainConfirmation of nasogastric tube placement 1. CXR should include the upper oesophagus and extend to below the diaphragm 2. The NG tube should remain in the midline down to the level of the diaphragm 3. The NG tube should bisect the carina. 4. The tip of the NG tube should be clearly visible and below the left hemidiaphragm. 5. The tip of the NG tube should be approximately 10 cm beyond the GOJ (i.e. within the stomach). .Confirmation of nasogastric tube placement 1. CXR should include the upper oesophagus and extend to below the diaphragm 2. The NG tube should remain in the midline down to the level of the diaphragm 3. The NG tube should bisect the carina. 4. The tip of the NG tube should be clearly visible and below the left hemidiaphragm. 5. The tip of the NG tube should be approximately 10 cm beyond the GOJ (i.e. within the stomach). . If ANY of the above criteria not met, NG is not safe to use. Discuss w senior/RadiologyCase 1: Correctly sited NG tube → Safe to useCase 2: Tip not visible → Not safe to use! → Repeat CXR → Specify in requestCase 3: NG coiled in the tracheobronchial tree → Not safe to use! → Remove and reinsert NGCase 4: NG not far enough inserted → Not safe to use! → Insert NG tube further → Re-check pH → May require repeat CXR SUMMARY: CXR • ALWAYS CHECK PATIENT DETAILS • COMPARE TO PREVIOUS IMAGING IF AVAILABLE • ALWAYS PLACE IN CLINICAL CONTEXT • ALWAYS GATHER MORE INFORMATION WHEN BEING HANDED OVER INVESTIGATIONS TO CHASE IF IN DOUBT – ASK FOR HELP CALL SHO/MEDICAL SPR/RADIOLOGY CHECK YOUR LOCAL PROTOCOL FOR CONFIRMATION OF NG TUBE PLACEMENTThank you for coming! Boris.wagner@uhbw.nhs.uk PORTFOLIO Log 1-hour non-core teaching on Horus FEEDBACK Please complete feedback form after this session using the QR code above. CERTIFICATE Available once feedback completed!