ANXIETY….
Approach to patient – rapport, empathy
Good elicitation of anxiety symptoms
Psychological symptoms
Physical symptoms
Circumstances of anxious symptoms
Busy or crowded places
Generalised anxiety?
Social phobia?
Presence of panic disorder
Symptoms present
Frequency
Other symptoms
Avoidance
Anticipatory anxiety
Impacts on life
Restrictions on activities
General functioning
Presence of mood symptoms
General screening questions for presence of depressive symptoms
Establishes whether depressive symptoms are primary or secondary
Diagnosis of agoraphobia with panic attacks
D/D of ANXIETY DISORDER
Psychiatric disorders:
Depression
Schizo
Dementia
Drug/alcohol dependence
BDZ withdrawal
Physical disorders
Hyperthyroidism
Hypoglycaemia
Phaeochromocytoma
Manangement…
Psychological – reassurance, relaxation training, psychotherapy
Drugs – beta-blockers, BDZ
Clinical features of anxiety…
Phyiscal:
GI – dry mouth, dysphagia, epigastric pain, flatulence, diarrhoea
Respi – sensation of chest constriction, difficulty inhaling, over-breathing
CVS – palpitations, chest pain
Genitourinary – frequency, failure of erection, lack of libido
Nervous system – tinnitus, blurred vision, dizziness, headache, sleep disturbance
Psychological – apprehension and fear, irritability, difficulty concentrating, distractibility, restlessness, sensitivity to noise, depression, depersonalization, obsessional thoughts
Saturday, March 24, 2007
DEPRESSION
Assessment of Mood
Diurnal variation
Reactivity/circumstantiality
Assessment of Biological symptoms
Sleep + EMW
LOA + LOW
Low energy/ fatigue
Lack of motivation
Anhedonia
Reduced libido
Other symptoms
Low self-esteem/ Low self-confidence
Poor concentration and attention
Pessimism, hopelessness
Ideas of guilt and unworthiness
Suicidal ideation
Previous history of mania/hypomania
SUICIDALITY – mau mati kah?
Approach to the patient – rapport, empathy
Degree of preparation
Planning
Suicide note
Last acts
Circumstances of OD
Alone
Intervention unlikely
Precautions against discovery
After the act
Didn’t seek help
Stated wish to die
Believed act would result in death
Regrets its failure
Recent history of depressive symptoms
Current mental state
Relevant past psychiatric history
Past history of self-harm
Past psychiatric history
Current medication
Social history (alcohol/drug misuse)
RISK FACTORS OF SUICIDE
Living alone
Immigrant status
Recent bereavement/separation/divorce
Unemployment/retirement
Male sex
Older age
Family or previous history (affective disorder, suicide, alcohol abuse)
Previous suicide attempt
Drug/alcohol addiction
Severe depression/early dementia
Incapacitating, painful physical illness
DELIBERATE SELF HARM
Reason
Method
Suicidal intent
Risk factors for suicide
Psychiatric disease
Drug/alcohol abuse
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ABCIXIMAB – GP IIb/IIIa antagonist – prior or during PTCA
TRANSTUZUMAB – HER-2 positive breast cancer
PALIVIZUMAB – RSV prophylaxis in children
IMATINIB – chronic myeloid leukaemia
IRESSA (gefitinib) – metastatic lung cancer
BETA-INTERFERON – relapsing-remitting multiple sclerosis
ALPHA-INTERFERON – active Hepatitis C infection
INFLIXIMAB – relapsing Crohn’s disease, RA
ETANERCEPT – psoriasis, RA
ALEMTUZUMAB – chemotherapy resistant chronic lymphocytic leukaemia
RITUXIMAB – large B-cell non-Hodgkin lymphoma
“NEW THERAPEUTIC INTERVENTIONS IN 21ST CENTURY”
ABCIXIMAB – GP IIb/IIIa antagonist – prior or during PTCA
TRANSTUZUMAB – HER-2 positive breast cancer
PALIVIZUMAB – RSV prophylaxis in children
IMATINIB – chronic myeloid leukaemia
IRESSA (gefitinib) – metastatic lung cancer
BETA-INTERFERON – relapsing-remitting multiple sclerosis
ALPHA-INTERFERON – active Hepatitis C infection
INFLIXIMAB – relapsing Crohn’s disease, RA
ETANERCEPT – psoriasis, RA
ALEMTUZUMAB – chemotherapy resistant chronic lymphocytic leukaemia
RITUXIMAB – large B-cell non-Hodgkin lymphoma
Thursday, March 22, 2007
OCD
OBSESSIONS
Do thought/images/impulses come into your mind over and over again?
Can you describe them to me?
How do they make you feel (seem senseless/cause distress)?
How often do you have them?
Do you try to resist them?
Where do you think these thoughts come from (own thought/alien force)?
What do you do to relieve your distress because of these thoughts?
COMPULSIONS
Do you perform repetitive acts which you feel compelled to do?
Can you descirbe what you do?
Tell me what happens - when/why/how often?
What compels you to carry out these acts (obsessions)?
How do they make you feel (anxiety/pointless)?
What do you think would happen if you did not perform the act?
Are you able to resist? For how long? How does this make you feel?
OBSESSIONS
Do thought/images/impulses come into your mind over and over again?
Can you describe them to me?
How do they make you feel (seem senseless/cause distress)?
How often do you have them?
Do you try to resist them?
Where do you think these thoughts come from (own thought/alien force)?
What do you do to relieve your distress because of these thoughts?
COMPULSIONS
Do you perform repetitive acts which you feel compelled to do?
Can you descirbe what you do?
Tell me what happens - when/why/how often?
What compels you to carry out these acts (obsessions)?
How do they make you feel (anxiety/pointless)?
What do you think would happen if you did not perform the act?
Are you able to resist? For how long? How does this make you feel?
OCD
OBSESSIONS
Do thought/images/impulses come into your mind over and over again?
Can you describe them to me?
How do they make you feel (seem senseless/cause distress)?
How often do you have them?
Do you try to resist them?
Where do you think these thoughts come from (own thought/alien force)?
What do you do to relieve your distress because of these thoughts?
COMPULSIONS
Do you perform repetitive acts which you feel compelled to do?
Can you descirbe what you do?
Tell me what happens - when/why/how often?
What compels you to carry out these acts (obsessions)?
How do they make you feel (anxiety/pointless)?
What do you think would happen if you did not perform the act?
Are you able to resist? For how long? How does this make you feel?
OBSESSIONS
Do thought/images/impulses come into your mind over and over again?
Can you describe them to me?
How do they make you feel (seem senseless/cause distress)?
How often do you have them?
Do you try to resist them?
Where do you think these thoughts come from (own thought/alien force)?
What do you do to relieve your distress because of these thoughts?
COMPULSIONS
Do you perform repetitive acts which you feel compelled to do?
Can you descirbe what you do?
Tell me what happens - when/why/how often?
What compels you to carry out these acts (obsessions)?
How do they make you feel (anxiety/pointless)?
What do you think would happen if you did not perform the act?
Are you able to resist? For how long? How does this make you feel?
Anxiety disorders
Start with general open questions
I understand you have had problems with anxiety
Can you tell me what you mean by that?
Do you feel tense, on edge, keyed up?
Do you have difficulty relaxing?
Do you feel worried or nervous?
Then home in on specific symptoms
Can I suggest some of the things you may be feeling or experiencing?
Anxiety Symptoms - 3 main groups
1. Physical
2. Thoughts /psychological
3. Behaviour
Physical -tiredness, insomnia, headache, dizziness, blurred vision, ringing in the ears, tightness in the throat, dry mouth, feeling of choking, tense and stiff shoulder, racing heart, unable to catch breath, tight chest, fast and shallow breathing, churning stomach, feeling sick, tense muscles, sore joints, sweating, needing the toilet, loss of libido, pins and needles, weekeness in legs, legs like jelly..
Thoughts - restlessness, irritability, poor concentration, fear of death, heart attack or nervous breakdown
Behaviour - avoidance, running away from an anxiety provoking situation, these behaviours are maintaining factors
Circumstances of these symptoms
How long?
How often?
Where?
When - tirggers VS out of the blue
Discrete episodes of panic VS generalised anxiety
Avoidance
Anticipatory anxiety
PANIC ATTACKS vs GENERALISED ANXIETY DISORDER
Do you have this feeling all the time?
Do you ever have panic attacks?
when your anxiety is overwhelming?
when you feel you're going to die?
what do you do when this happens? (run home?)
Panic attacks
Recurrent attacks of severe anxiety
Attacks last for minutes only
Not restricted to any particular situation
Symptoms - palpitations/choking/dizzy
Secondary fear of dying/losing control/going mad
Several severe attacks of autonomic anxiety have occurred within a period of 1 month
- in circumstances with no objective danger
-no predictable situation
-comparative freedom between attacks
Generalised anxiety disorder
Anxiety which is generalised and persistent
Free-floating - not predominant in any environment
Continuous feeling of nervous/trembling/muscle tension/sweats/dizzy/palpitations
Must suffer primary symptoms of anxiety most days for at least several weeks at a time (apprehension/motor tension/autonomic overactivity)
Start with general open questions
I understand you have had problems with anxiety
Can you tell me what you mean by that?
Do you feel tense, on edge, keyed up?
Do you have difficulty relaxing?
Do you feel worried or nervous?
Then home in on specific symptoms
Can I suggest some of the things you may be feeling or experiencing?
Anxiety Symptoms - 3 main groups
1. Physical
2. Thoughts /psychological
3. Behaviour
Physical -tiredness, insomnia, headache, dizziness, blurred vision, ringing in the ears, tightness in the throat, dry mouth, feeling of choking, tense and stiff shoulder, racing heart, unable to catch breath, tight chest, fast and shallow breathing, churning stomach, feeling sick, tense muscles, sore joints, sweating, needing the toilet, loss of libido, pins and needles, weekeness in legs, legs like jelly..
Thoughts - restlessness, irritability, poor concentration, fear of death, heart attack or nervous breakdown
Behaviour - avoidance, running away from an anxiety provoking situation, these behaviours are maintaining factors
Circumstances of these symptoms
How long?
How often?
Where?
When - tirggers VS out of the blue
Discrete episodes of panic VS generalised anxiety
Avoidance
Anticipatory anxiety
PANIC ATTACKS vs GENERALISED ANXIETY DISORDER
Do you have this feeling all the time?
Do you ever have panic attacks?
when your anxiety is overwhelming?
when you feel you're going to die?
what do you do when this happens? (run home?)
Panic attacks
Recurrent attacks of severe anxiety
Attacks last for minutes only
Not restricted to any particular situation
Symptoms - palpitations/choking/dizzy
Secondary fear of dying/losing control/going mad
Several severe attacks of autonomic anxiety have occurred within a period of 1 month
- in circumstances with no objective danger
-no predictable situation
-comparative freedom between attacks
Generalised anxiety disorder
Anxiety which is generalised and persistent
Free-floating - not predominant in any environment
Continuous feeling of nervous/trembling/muscle tension/sweats/dizzy/palpitations
Must suffer primary symptoms of anxiety most days for at least several weeks at a time (apprehension/motor tension/autonomic overactivity)
DEPRESSION...
Core symptoms...
Low mood
Anhedonia
Reduced energy
Other symptoms:
Reduced concentration
Loss of appetite with weight loss
sleep disturbance - 1. early morning wakening, 2. initial insomnia
low self esteem
worthlessness and guilt
feeling hopeless about the future
suicidal ideation
Investigating low mood
Biological
Physical examination
Bloods - to exclude physical causes of low mood
Urinary drug screen
? based on the results do further.. CXR / ECF / EEG / CT head
Psychological
Rating scale (HADS)
Psychology referral
Social
Collateral history
OT assessment
SW assessment
Management of depression
Biological
Antidepressants - SSRIs, SNRIs
Adjuncts e.g. Lithium
Other mood stabilisers - sodium valproate
ECT
Psychological
Psychology referral
CBT
Psychodynamic psychotherapy
IPT / DBT / CAT (cognitive analytical therapy)
Social
Involve the multidisciplinary team
OT assessment
Family support, involvement and psychoeducation (to avoid stigmatisation)
Support groups
Social work ( good if got children on board)
Core symptoms...
Low mood
Anhedonia
Reduced energy
Other symptoms:
Reduced concentration
Loss of appetite with weight loss
sleep disturbance - 1. early morning wakening, 2. initial insomnia
low self esteem
worthlessness and guilt
feeling hopeless about the future
suicidal ideation
Investigating low mood
Biological
Physical examination
Bloods - to exclude physical causes of low mood
Urinary drug screen
? based on the results do further.. CXR / ECF / EEG / CT head
Psychological
Rating scale (HADS)
Psychology referral
Social
Collateral history
OT assessment
SW assessment
Management of depression
Biological
Antidepressants - SSRIs, SNRIs
Adjuncts e.g. Lithium
Other mood stabilisers - sodium valproate
ECT
Psychological
Psychology referral
CBT
Psychodynamic psychotherapy
IPT / DBT / CAT (cognitive analytical therapy)
Social
Involve the multidisciplinary team
OT assessment
Family support, involvement and psychoeducation (to avoid stigmatisation)
Support groups
Social work ( good if got children on board)
SUICIDE RISK ASSESSMENT
CIRCUMSTANCES
What tablets did you take?
How many tablets?
Whose tablets?
Where did you take the tablets?
What were you doing before?
Were you alone?
How did you end up in the hospital?
IMPULSIVE vs. PLANNED
Tell anybody? (have you told anybody before you took it?
Suicide note / wills / final acts?
How long thinking about it? (1 day? 6 weeks?)
TODAY
Purpose of OD?
Did they believe it would kill them?
Reason for OD?
How do they feel about it today?
Still want to die?
Plans/preparation?
Future?
PSYCHIATRIC ILLNESS
Depression (you mentioned you have been on amitryptiline, can you tell me how your mood has been? energy? interest? sleep? appetite?)
Alcohol / Drugs
Self harm
Psychosis
Tuesday, March 20, 2007
Acute Respiratory Day 21st March 2007.
Pre-course material
1. Acute exacerbation of COPD
Exacerbations may be associated with:
Increased dyspnoea
Increased sputum purulence
Increased sputum volume
Indications for hospitalisation:
The presence of high risk co-morbid conditions including pneumonia, cardiac arrhythmia, congestive heart failure, uncontrolled diabetes mellitus, renal or liver failure
Inadequate response of symptoms to outpatient management
Inability to eat or sleep due to symptoms
Worsening hypoxaemia
Worsening hypercapnia
Change in mental status
Inability of the patient to care for her/himself (lack of home support)
Uncertain diagnosis
Investigations:
§ Routine biochemistry and haematology
§ Arterial blood gases on air if SaO2 on air< 92%
§ CXR to exclude other diagnoses (e.g. pneumonia, heart failure, pneumothorax)
§ Sputum culture
§ ECG if cardiac arrhythmia or ischaemia suspected
Principles of in-patient management:
§ Bronchodilators: regular nebulised salbutamol 2.5-5mg up to 2 hourly and ipratropium 500 mcg qds
§ Prednisolone: 40 mg orally for 7 days then stop if not on maintenance prednisolone
§ Antibiotics if two of:
§ increased breathlessness
§ increased sputum volume
§ sputum purulence
o Amoxicillin
o Fluoroquinolones, macrolide or augmentin if recent treatment with amoxycillin
§ DVT prophylaxis
§ Controlled oxygen therapy
o Primary aim to maintain oxygen saturation >90%
o See flow diagram
§ Remember that respiratory failure may be chronic
§ Nicotine replacement therapy for smokers
If not improving consider:
§ Alternative diagnosis
§ Adding IV aminophylline or salbutamol
(if patient is on oral theophylline already, omit aminophylline loading dose)
§ NIV or IV doxapram if respiratory acidosis develops
ITU referral
When to discharge:
Remember Early Supported Discharge programmes
Haemodynamic stablility
Oxygenation returned to baseline
Off parenteral therapy for 12-24 hrs
Inhaled β2-agonist therapy required less frequently
Symptoms returned to baseline
Mobility returned to pre-morbid state
Follow-up and home care arrangements completed (e.g. visiting nurse, oxygen delivery, home nebuliser if indicated, meal provisions etc)
Review medications prior to discharge:
Check inhaler technique
If FEV1 <50% predicted and 2 or more exacerbations per year consider
addition of ICS
Consider tiotropium
Consider carbocysteine to aid sputum clearance
Smoking cessation advice
Follow-up in respiratory clinic and PFT in 6-8 weeks if new diagnosis
of COPD or no lung function testing has been performed previously
Follow-up after exacerbation of COPD:
Review PFT findings and diagnosis
Evaluate improvement in symptoms and adjust the treatment regime
Re-assess blood gas profile if patient may require supplemental home oxygen
Refer pulmonary rehabilitation if suitable
Reinforce smoking cessation
2. Community Acquired Pneumonia
Aetiology:
Causes are only identified in 10-25% of cases, so treatment is usually empirical.
Streptococcus pneumoniae
§ the most common pathogen (40%) and all empirical antibiotic regimes must cover this organism
§ typically causes pleuritc chest pain
H. influenzae
§ the second most common pathogen (10%)
Mycoplasma pneumoniae
§ occurs in epidemics every four years
Legionella pneumophila
§ water distribution systems, foreign travel, especially to the Mediterranean, person-to person transmission rare
§ causes more severe pneumonia
§ associated with confusion, GI symptoms especially diarrhoea, hyponatraemia and abnormal LFTs
Staphylococcus aureus
§ causes more severe pneumonia
§ complicates influenza infection
Gram negative bacilli, Chlamydia psittaci/pneumoniae and Coxiella burnetii are uncommon causes of CAP.
Clinical features:
§ symptoms and signs consistent with acute LRTI
§ new radiographic shadowing for which there is no other explanation
§ elderly patients are more likely to present with non-specific symptoms and are less likely to have a fever
Assessment of severity:
CURB-65 score predicts mortality or need for ITU admission
One point for each of
C confusion
U urea >7 mmol/L
R RR ≥30/min
B Systolic BP <90mmHg or diastolic BP ≤60 mmHg
65 age ≥ 65
Score
Mortality or need for ITU admission
Management
0
0.7%
out-patient treatment
1
3.2%
2
13%
Short stay in hospital or hospital supervised treatment
3
17%
Severe pneumonia requiring hospital
4
41.5%
admission
5
57%
Investigations:
§ CXR
§ Routine biochemistry, haematology & inflammatory markers
§ ABGs ~ to assess acidosis and need for oxygen therapy
Microbiology (routine)
§ blood cultures
§ sputum for C+S
§ acute serum sample for storage
§ pleural fluid for C+S
Microbiology (severe CAP)
§ consider urgent Gram stain of sputum
§ Pneumococcal antigen (urine)
§ Legionella antigen (urine, only detects L. pneumophila serogroup 1), culture (sputum and bronchial aspirate, needs to be requested specifically) and serology (acute and convalescent samples)
§ Atypical serology
§ Nose and throat swabs for respiratory viruses
Management:
§ Give oxygen therapy as required to maintain SaO2>92%
§ IV fluids to rehydrate unless contraindicated
§ Antibiotics
o Non-severe CAP (for those admitted to hospital for clinical reasons)
First-line oral amoxicillin and clarithromycin; second-line moxifloxacin or levofloxacin
o Severe CAP – IV ceftriaxone (or augmentin) and oral clarithromycin; second-line IV benzylpenicillin and levofloxacin/moxifloxacin
§ Analgesia
§ DVT prophylaxis
§ Nutritional support or NG feeding if malnourished or prolonged illness
Consider ITU referral if there is inability to maintain PaO2>8 kPa
and H+>45 nmol/L, decreasing conscious level or exhaustion,
progressive CO2 retention or shock.
Monitoring progress:
§ Monitor HR, RR, BP, mental status, temperature and SaO2 at least twice a day until improving
Follow-up:
§ CXR in 6 weeks to assess resolution
§ Consider bronchoscopy+/- CT chest and abdomen if incomplete radiographic clearing at follow-up
§ Take serum sample for convalescent serology (initial sample will only be analysed if follow-up sample is sent)
3. Pneumothorax
Definition:
Pneumothorax may be spontaneous or traumatic/iatrogenic. Spontaneous pneumothorax may be primary (usually in otherwise healthy patients) or secondary (in patients with chronic lung disease). It may be small ie <> 2cm rim of air.
Investigation:
Expiratory chest radiographs are not recommended for routine diagnosis. A lateral or lateral decubitus chest radiograph should be performed if the clinical suspicion of pneumothorax is high, but a PA radiograph is normal.
CT scanning is recommended when differentiating a pneumothorax from complex bullous lung disease is difficult, when aberrant tube placement is suspected, and when the plain chest radiograph is obscured by surgical emphysema.
Management:
Observation only:
Patients with small (<2cm) primary pneumothoraces and have minimal symptoms do not require intervention. They can be discharged safely with out-patient review in 1-2 weeks and advice to return if worsening breathlessness develops. Observation alone is appropriate in patients with secondary pneumothoraces only if they have minimal symptoms and the pneumothorax is very small (<1cm). These patients should be admitted for 24 hours.
Simple aspiration:
Simple aspiration is recommended as the first line treatment for all primary pneumothoraces requiring intervention and is only recommended as an initial treatment in small (<2cm) secondary pneumothoraces in minimally breathless patients under the age of 50 years.
Patients with secondary pneumothoraces treated successfully with simple aspiration should be admitted to hospital and observed for at least 24 hours before discharge.
Repeated aspiration is reasonable for primary pneumothoraces when the first aspiration has been unsuccessful (i.e. patient still symptomatic) and a volume of <2.5 L is aspirated in the first attempt.
Tension pneumothorax is a medical emergency & requires immediate decompression with a large bore venflon inserted into the 2nd intercostal space mid-clavicular line, followed by chest drain insertion
Insert an intravenous cannula attached to a three-way tap and a 50ml syringe in the 2nd intercostal space mid-clavicular line.
Stop if there is resistance, the patient coughs excessively, or more than 2.5 L (50x50ml syringe) is aspirated.
Repeat CXR ~ the procedure has been successful if a small or no pneumothorax remains.
Chest drain:
A chest drain is required if simple aspiration is unsuccessful or in large (>2cm) secondary pneumothoraces.
A bubbling chest tube should never be clamped. There is no evidence that large tubes (20–24F) are any better than small tubes (10–14F). It should remain in place until the lung has re-expanded and the drain has stopped bubbling for 24 hrs. It should then be removed and a repeat CXR arranged.
Senior help should be sought where:
§ The lung does not re-expand with a chest drain
§ The drain continues to bubble after 24 hours
§ The lung collapses again after removal of chest drain
Suction should be added if there is persistent air leak or if the lung fails to re-expand after 48 hrs.
Flow-chart of management of spontaneous pneumothorax
Chronic Lung Disease
Aspiration
?successful
Primary pneumothorax
Secondary pneumothorax
Rim of air>2cm on CXR
Significant dyspnoea
Rim of air>2cm
Significant dyspnoea or age>50
Discharge and follow-up in clinic
Intercostal drain
Discharge and follow-up in clinic
Consider repeat aspiration
?successful
Admit for 24 hours
Aspiration
?successful
No
Yes
Yes
No
No
No
No
Yes
Yes
Yes
No
Yes
Yes
No
Follow-up:
7-10 days in the Respiratory Clinic with repeat CXR.
§ Advise patient to return if symptoms worsen or recur
§ Advise patient not to fly until reviewed
§ Patients can fly safely 6 weeks after resolution of pneumothorax or surgery for pneumothorax
§ Diving should be avoided for life unless secure definitive surgery such as surgical pleurectomy has been performed
4. PULMONARY EMBOLISM
Pulmonary embolism is a difficult diagnosis to make. The following points should be remembered:
§ PE is easily missed in severe cardiorespiratory disease, in the elderly, and where the only symptom is breathlessness.
§ Most patients with PE are breathless and/or tachypnoeic (RR>20/min). In the absence of these, symptoms are usually due to another cause.
§ PE is rare if age<40 with no risk factors.
§ Oestrogens are only a minor risk factor.
Presentation:
Small PE – pleuritic chest pain+/- haemoptysis
Large PE – SOB, hypoxia, acute right heart strain on ECG, right heart dilatation on Echo
Massive PE – circulatory collapse
As most patients do not fit neatly into these categories, PE is both over- and under-diagnosed.
Major risk factors (relative risk 5-20 )
Surgery
§ Major abdominal, pelvic and orthopaedic surgery
§ Knee/hip replacement
§ Post-operative intensive care
Obstetrics
§ Late pregnancy
§ Puerperium
§ Caesarian section
Lower limb problems
§ Varicose veins
§ Fracture
Malignancy
§ Abdominal/pelvic
§ Advanced/metastatic
Reduced mobility
§ Hospitalisation
§ Institutional care
Previous DVT/PE
Minor risk factors (relative risk 2-4) include cardiopulmonary disease, inflammatory bowel disease, obesity, long distance travel, neurological disability, OCP, HRT and thrombotic disorders.
Assessment of clinical probability:
D-dimer should only be measured following assessment of clinical probability. It is not useful in patients with high clinical probability as false negative rates are unacceptably high in this group.
Investigations:
Most initial investigations are aimed towards excluding other diagnoses e.g. pneumonia, pneumothorax or cardiac disease.
§ ABG
§ CXR
§ ECG
§ PEFR
§ D-Dimer
The D-dimer assay (Vidas) has a high negative predictive power for PE in patients where the pre-test probability is low or intermediate, therefore a negative D-dimer reliably excludes PE in these groups. If the pre-test probability is high, D-dimer is not sufficiently sensitive to detect PE. Further lung imaging is required even if D-dimer is negative, therefore there is no value in checking D-dimer in this group. D-dimer can be positive (>500 u/l) in many other acute medical conditions.
A truly normal V/Q scan reliably excludes any significant PE and a high probability scan indicates about 80% probability of PE depending on the pre-test probability. Unfortunately most scans fall into the ‘intermediate’ classification due to other coexisting cardiopulmonary disease. It should only be performed if it is available on site, if CXR is normal and there is no significant underlying cardiopulmonary disease.
CT pulmonary angiogram (CTPA) has taken over from pulmonary angiogram as the ‘gold standard’. It is the first line investigation if CXR is abnormal or if V/Q scanning is not available on site. It should ideally be performed within 24 hours of presentation. It may provide other diagnoses if PE is excluded.
Echocardiogram may be useful in patients with PE large enough to cause cardiovascular collapse. It can detect right ventricular dilatation /raised pulmonary artery pressure or intracardiac thrombus.
DVT confirmed on ultrasound scan of leg veins can be used as a surrogate marker for PE. A negative scan does not exclude PE.
Thrombophilia screen should be performed in patients < 50 years of age with recurrent PE or a strong family history of proven DVT/PE.
Management:
LMWH should be given until PE is proven or excluded. Once PE is confirmed, patient should be started on warfarin and treatment should last for
– 3 months if it is a consequence of a clear precipitating event with no continuing risk factors
– 6 months for first idiopathic episode
– life-long for recurrent episodes or continuing major risk factors
Some patients are treated with LMWH instead of warfarin due to consideration of potential drug interactions e.g. patients with underlying malignancy undergoing chemotherapy.
Thrombolysis is indicated in massive PE with circulatory collapse. It may be life-saving in peri-arrest situations. A 50mg bolus of alteplase followed by 100mg over 2 hours is given.
5. Acute severe asthma
Assess severity
Acute severe asthma Life threatening asthma Near Fatal asthma
· PEF: 33-50% best/predicted h PEF <33% best/predicted hRaised paCO2
· Can’t complete sentences h SpO2 <92%
· Respiration >25 breaths/min h Silent chest/cyanosis/
· Pulse >110 beats/min poor respiratory effort
h Exhaustion/confusion/coma
h Measure arterial blood gases
0 High H+
0 PaO2 <8KPa [irrespective of oxygen treatment]
0 Normal PaCO2
Immediate treatment
· Oxygen: High flow (40-60%) ~ aim for SpO2 >92
· Nebulised salbutamol 5 mg + Nebulised ipratropium bromide 0.5 mg via oxygen-driven nebuliser, continue 4-6 hourly
· Prednisolone: 50 mg daily for at least 5 days or until recovery or IV hydrocortisone 100 mg 6 hourly if oral route not possible
If patient not improving within 15-30 min or Life threatening or Near fatal attack
· Discuss with middle grade/senior clinician
· Nebulised salbutamol: give every 15 minutes or continuously 10 mg hourly [Sidestream nebuliser]
· Add IV magnesium: 1.2-2g infusion over 20 minutes
· Other treatments: Middle grade/senior clinician may consider: IV salbutamol or IV aminophylline; alerting on-call anaesthetist
Discharge planning
· Check inhaler technique & assess adherence with therapy h Stop nebulised therapy 24 hrs before discharge
· Review chronic drug treatment h Written asthma action plan
· Smoking cessation advice h Respiratory clinic appointment in 4-6 wks
Monitoring/investigations
· Oximetry: maintain O2 >92%
· Repeat blood gases if :
- Initial paO2 <8>92%
- PCO2 normal or raised
· PEF
· Chest-ray: to exclude pneumothorax or pneumonia
6. ARDS – Acute Respiratory Distress Syndrome
ARDS is a disorder first described in 1967. It causes acute onset of respiratory distress, with severe breathlessness and hypoxia, often not improved by additional oxygen. Patients often become very sick very quickly and the majority of them will require to be ventilated in the intensive care unit.
ARDS can be diagnosed if the patient satisfies the following criteria
NAECC Criteria – North American and European Consensus Conference Criteria
· Known predisposing cause
· Acute onset
· Bilateral infiltrates on CXR
· Pulmonary artery occlusion pressure <18mmHg or no clinical signs heart
Failure
· PaO2/FiO2<200mmHg
ARDS can be caused by a variety of stimuli, not all of them act directly on the lung. These causes can be subdivided into direct (acting on the lung) and indirect (acting elsewhere) causes.
Direct - pneumonia
Pulmonary aspiration
Lung contusion
Fat embolism
Near drowning
Inhalational injury
Reperfusion injury
Indirect - non-pulmonary sepsis
Multiple trauma
Massive transfusion
Pancreatitis
Coronary bypass
Pathophysiology
ARDS causes pulmonary oedema due to damage to the alveolar-capillary membrane (not like heart failure, where the oedema is due to increased hydrostatic pressure). There is then a leak of fluid, proteins and inflammatory infiltrate (neutrophils, cytokines, proteases) into the alveolus. This fills the alveoli and makes them stiff and they are then unable to take part in gas exchange. This process can affect a variable proportion of the lung. This is why patient with ARDS are severely hypoxic, it is almost as though they are working on 1 lung or even less depending on the severity. Because the lung is so stiff, they often have difficulty taking big breaths and breath with rapid shallow breaths – another reason why they often need ventilated. All these changes can occur within 12-36 hours of the stimulating cause.
Epidemiology
The incidence of ARDS is variable but is about 5: 100 000. 20% of all patients who require ventilation in ICU fulfil the criteria for ARDS. You may not see it much on the wards as patients will often be so sick that they go straight from A&E or theatre to ICU so it is probably commoner than you think.
Mortality rate has not changed much in the last 30-40 years and is around 30-60% depending on cause and the premorbid health and age of the patient.
Only 10-15% of patients will die of respiratory failure. The others die of non-pulmonary organ failure, either because they are critically ill in some other way or because the severe hypoxia has damaged other organs. Of the patients who survive, most of them will regain full functional ability but a fair amount will have residual mildly deranged pulmonary function tests.
Treatment
As with any critically ill patient, general supportive management is very important from the outset. This includes:-
· Good nutrition
· Thromboembolism prophylaxis
· Gastric prophylaxis
· Careful fluid balance
In addition, the way patients are ventilated is also very important. The ARDSNet group published a paper in 2000 looking at a different way of ventilating patients and showed that this can reduce mortality by 22%. The change in strategy is due to the thinking that a large proportion of the lung is unable to take part in ventilation as the alveoli are full of ‘gunk’. Therefore, if we were to ventilate a lung normally, the unaffected lung would get a much greater tidal volume than it needs, stretching it and causing damage. The aim of the ventilation strategy is to do as little damage to the normal lung as possible, while aiming to try to ‘recruit’ as much of the damaged lung as we can and allow it to take part in ventilation.
This is done by:-
· Smaller tidal volumes – to reduce the chance of overdistension of normal lung
· Limiting the maximum pressure produced in the lungs
· Adding an additional pressure – PEEP – to hold open areas of lung which would otherwise collapse down
· Trying to decrease the amount of oxygen to <60% as soon as possible
· Tolerating a higher CO2 level than normal
Other treatments are tried now and again but none have been shown to produce any increase in survival rates. These include:-
· Prone ventilation – lying patients on their face to ventilate
· Inhaled nitric oxide
· ECMO – extra corporeal membrane oxygenation
· High dose steroids in chronic cases
Summary
Ø ARDS is a disorder causing acute onset respiratory distress, breathlessness and severe hypoxia due to a number of predisposing causes.
Ø Most patients will require ventilation in ICU.
Ø Mortality continues to remain high.
Ø Care and attention to general supportive management is very important.
Ø Patients with ARDS should be ventilated in a specific manner to avoid further lung damage.
Pre-course material
1. Acute exacerbation of COPD
Exacerbations may be associated with:
Increased dyspnoea
Increased sputum purulence
Increased sputum volume
Indications for hospitalisation:
The presence of high risk co-morbid conditions including pneumonia, cardiac arrhythmia, congestive heart failure, uncontrolled diabetes mellitus, renal or liver failure
Inadequate response of symptoms to outpatient management
Inability to eat or sleep due to symptoms
Worsening hypoxaemia
Worsening hypercapnia
Change in mental status
Inability of the patient to care for her/himself (lack of home support)
Uncertain diagnosis
Investigations:
§ Routine biochemistry and haematology
§ Arterial blood gases on air if SaO2 on air< 92%
§ CXR to exclude other diagnoses (e.g. pneumonia, heart failure, pneumothorax)
§ Sputum culture
§ ECG if cardiac arrhythmia or ischaemia suspected
Principles of in-patient management:
§ Bronchodilators: regular nebulised salbutamol 2.5-5mg up to 2 hourly and ipratropium 500 mcg qds
§ Prednisolone: 40 mg orally for 7 days then stop if not on maintenance prednisolone
§ Antibiotics if two of:
§ increased breathlessness
§ increased sputum volume
§ sputum purulence
o Amoxicillin
o Fluoroquinolones, macrolide or augmentin if recent treatment with amoxycillin
§ DVT prophylaxis
§ Controlled oxygen therapy
o Primary aim to maintain oxygen saturation >90%
o See flow diagram
§ Remember that respiratory failure may be chronic
§ Nicotine replacement therapy for smokers
If not improving consider:
§ Alternative diagnosis
§ Adding IV aminophylline or salbutamol
(if patient is on oral theophylline already, omit aminophylline loading dose)
§ NIV or IV doxapram if respiratory acidosis develops
ITU referral
When to discharge:
Remember Early Supported Discharge programmes
Haemodynamic stablility
Oxygenation returned to baseline
Off parenteral therapy for 12-24 hrs
Inhaled β2-agonist therapy required less frequently
Symptoms returned to baseline
Mobility returned to pre-morbid state
Follow-up and home care arrangements completed (e.g. visiting nurse, oxygen delivery, home nebuliser if indicated, meal provisions etc)
Review medications prior to discharge:
Check inhaler technique
If FEV1 <50% predicted and 2 or more exacerbations per year consider
addition of ICS
Consider tiotropium
Consider carbocysteine to aid sputum clearance
Smoking cessation advice
Follow-up in respiratory clinic and PFT in 6-8 weeks if new diagnosis
of COPD or no lung function testing has been performed previously
Follow-up after exacerbation of COPD:
Review PFT findings and diagnosis
Evaluate improvement in symptoms and adjust the treatment regime
Re-assess blood gas profile if patient may require supplemental home oxygen
Refer pulmonary rehabilitation if suitable
Reinforce smoking cessation
2. Community Acquired Pneumonia
Aetiology:
Causes are only identified in 10-25% of cases, so treatment is usually empirical.
Streptococcus pneumoniae
§ the most common pathogen (40%) and all empirical antibiotic regimes must cover this organism
§ typically causes pleuritc chest pain
H. influenzae
§ the second most common pathogen (10%)
Mycoplasma pneumoniae
§ occurs in epidemics every four years
Legionella pneumophila
§ water distribution systems, foreign travel, especially to the Mediterranean, person-to person transmission rare
§ causes more severe pneumonia
§ associated with confusion, GI symptoms especially diarrhoea, hyponatraemia and abnormal LFTs
Staphylococcus aureus
§ causes more severe pneumonia
§ complicates influenza infection
Gram negative bacilli, Chlamydia psittaci/pneumoniae and Coxiella burnetii are uncommon causes of CAP.
Clinical features:
§ symptoms and signs consistent with acute LRTI
§ new radiographic shadowing for which there is no other explanation
§ elderly patients are more likely to present with non-specific symptoms and are less likely to have a fever
Assessment of severity:
CURB-65 score predicts mortality or need for ITU admission
One point for each of
C confusion
U urea >7 mmol/L
R RR ≥30/min
B Systolic BP <90mmHg or diastolic BP ≤60 mmHg
65 age ≥ 65
Score
Mortality or need for ITU admission
Management
0
0.7%
out-patient treatment
1
3.2%
2
13%
Short stay in hospital or hospital supervised treatment
3
17%
Severe pneumonia requiring hospital
4
41.5%
admission
5
57%
Investigations:
§ CXR
§ Routine biochemistry, haematology & inflammatory markers
§ ABGs ~ to assess acidosis and need for oxygen therapy
Microbiology (routine)
§ blood cultures
§ sputum for C+S
§ acute serum sample for storage
§ pleural fluid for C+S
Microbiology (severe CAP)
§ consider urgent Gram stain of sputum
§ Pneumococcal antigen (urine)
§ Legionella antigen (urine, only detects L. pneumophila serogroup 1), culture (sputum and bronchial aspirate, needs to be requested specifically) and serology (acute and convalescent samples)
§ Atypical serology
§ Nose and throat swabs for respiratory viruses
Management:
§ Give oxygen therapy as required to maintain SaO2>92%
§ IV fluids to rehydrate unless contraindicated
§ Antibiotics
o Non-severe CAP (for those admitted to hospital for clinical reasons)
First-line oral amoxicillin and clarithromycin; second-line moxifloxacin or levofloxacin
o Severe CAP – IV ceftriaxone (or augmentin) and oral clarithromycin; second-line IV benzylpenicillin and levofloxacin/moxifloxacin
§ Analgesia
§ DVT prophylaxis
§ Nutritional support or NG feeding if malnourished or prolonged illness
Consider ITU referral if there is inability to maintain PaO2>8 kPa
and H+>45 nmol/L, decreasing conscious level or exhaustion,
progressive CO2 retention or shock.
Monitoring progress:
§ Monitor HR, RR, BP, mental status, temperature and SaO2 at least twice a day until improving
Follow-up:
§ CXR in 6 weeks to assess resolution
§ Consider bronchoscopy+/- CT chest and abdomen if incomplete radiographic clearing at follow-up
§ Take serum sample for convalescent serology (initial sample will only be analysed if follow-up sample is sent)
3. Pneumothorax
Definition:
Pneumothorax may be spontaneous or traumatic/iatrogenic. Spontaneous pneumothorax may be primary (usually in otherwise healthy patients) or secondary (in patients with chronic lung disease). It may be small ie <> 2cm rim of air.
Investigation:
Expiratory chest radiographs are not recommended for routine diagnosis. A lateral or lateral decubitus chest radiograph should be performed if the clinical suspicion of pneumothorax is high, but a PA radiograph is normal.
CT scanning is recommended when differentiating a pneumothorax from complex bullous lung disease is difficult, when aberrant tube placement is suspected, and when the plain chest radiograph is obscured by surgical emphysema.
Management:
Observation only:
Patients with small (<2cm) primary pneumothoraces and have minimal symptoms do not require intervention. They can be discharged safely with out-patient review in 1-2 weeks and advice to return if worsening breathlessness develops. Observation alone is appropriate in patients with secondary pneumothoraces only if they have minimal symptoms and the pneumothorax is very small (<1cm). These patients should be admitted for 24 hours.
Simple aspiration:
Simple aspiration is recommended as the first line treatment for all primary pneumothoraces requiring intervention and is only recommended as an initial treatment in small (<2cm) secondary pneumothoraces in minimally breathless patients under the age of 50 years.
Patients with secondary pneumothoraces treated successfully with simple aspiration should be admitted to hospital and observed for at least 24 hours before discharge.
Repeated aspiration is reasonable for primary pneumothoraces when the first aspiration has been unsuccessful (i.e. patient still symptomatic) and a volume of <2.5 L is aspirated in the first attempt.
Tension pneumothorax is a medical emergency & requires immediate decompression with a large bore venflon inserted into the 2nd intercostal space mid-clavicular line, followed by chest drain insertion
Insert an intravenous cannula attached to a three-way tap and a 50ml syringe in the 2nd intercostal space mid-clavicular line.
Stop if there is resistance, the patient coughs excessively, or more than 2.5 L (50x50ml syringe) is aspirated.
Repeat CXR ~ the procedure has been successful if a small or no pneumothorax remains.
Chest drain:
A chest drain is required if simple aspiration is unsuccessful or in large (>2cm) secondary pneumothoraces.
A bubbling chest tube should never be clamped. There is no evidence that large tubes (20–24F) are any better than small tubes (10–14F). It should remain in place until the lung has re-expanded and the drain has stopped bubbling for 24 hrs. It should then be removed and a repeat CXR arranged.
Senior help should be sought where:
§ The lung does not re-expand with a chest drain
§ The drain continues to bubble after 24 hours
§ The lung collapses again after removal of chest drain
Suction should be added if there is persistent air leak or if the lung fails to re-expand after 48 hrs.
Flow-chart of management of spontaneous pneumothorax
Chronic Lung Disease
Aspiration
?successful
Primary pneumothorax
Secondary pneumothorax
Rim of air>2cm on CXR
Significant dyspnoea
Rim of air>2cm
Significant dyspnoea or age>50
Discharge and follow-up in clinic
Intercostal drain
Discharge and follow-up in clinic
Consider repeat aspiration
?successful
Admit for 24 hours
Aspiration
?successful
No
Yes
Yes
No
No
No
No
Yes
Yes
Yes
No
Yes
Yes
No
Follow-up:
7-10 days in the Respiratory Clinic with repeat CXR.
§ Advise patient to return if symptoms worsen or recur
§ Advise patient not to fly until reviewed
§ Patients can fly safely 6 weeks after resolution of pneumothorax or surgery for pneumothorax
§ Diving should be avoided for life unless secure definitive surgery such as surgical pleurectomy has been performed
4. PULMONARY EMBOLISM
Pulmonary embolism is a difficult diagnosis to make. The following points should be remembered:
§ PE is easily missed in severe cardiorespiratory disease, in the elderly, and where the only symptom is breathlessness.
§ Most patients with PE are breathless and/or tachypnoeic (RR>20/min). In the absence of these, symptoms are usually due to another cause.
§ PE is rare if age<40 with no risk factors.
§ Oestrogens are only a minor risk factor.
Presentation:
Small PE – pleuritic chest pain+/- haemoptysis
Large PE – SOB, hypoxia, acute right heart strain on ECG, right heart dilatation on Echo
Massive PE – circulatory collapse
As most patients do not fit neatly into these categories, PE is both over- and under-diagnosed.
Major risk factors (relative risk 5-20 )
Surgery
§ Major abdominal, pelvic and orthopaedic surgery
§ Knee/hip replacement
§ Post-operative intensive care
Obstetrics
§ Late pregnancy
§ Puerperium
§ Caesarian section
Lower limb problems
§ Varicose veins
§ Fracture
Malignancy
§ Abdominal/pelvic
§ Advanced/metastatic
Reduced mobility
§ Hospitalisation
§ Institutional care
Previous DVT/PE
Minor risk factors (relative risk 2-4) include cardiopulmonary disease, inflammatory bowel disease, obesity, long distance travel, neurological disability, OCP, HRT and thrombotic disorders.
Assessment of clinical probability:
D-dimer should only be measured following assessment of clinical probability. It is not useful in patients with high clinical probability as false negative rates are unacceptably high in this group.
Investigations:
Most initial investigations are aimed towards excluding other diagnoses e.g. pneumonia, pneumothorax or cardiac disease.
§ ABG
§ CXR
§ ECG
§ PEFR
§ D-Dimer
The D-dimer assay (Vidas) has a high negative predictive power for PE in patients where the pre-test probability is low or intermediate, therefore a negative D-dimer reliably excludes PE in these groups. If the pre-test probability is high, D-dimer is not sufficiently sensitive to detect PE. Further lung imaging is required even if D-dimer is negative, therefore there is no value in checking D-dimer in this group. D-dimer can be positive (>500 u/l) in many other acute medical conditions.
A truly normal V/Q scan reliably excludes any significant PE and a high probability scan indicates about 80% probability of PE depending on the pre-test probability. Unfortunately most scans fall into the ‘intermediate’ classification due to other coexisting cardiopulmonary disease. It should only be performed if it is available on site, if CXR is normal and there is no significant underlying cardiopulmonary disease.
CT pulmonary angiogram (CTPA) has taken over from pulmonary angiogram as the ‘gold standard’. It is the first line investigation if CXR is abnormal or if V/Q scanning is not available on site. It should ideally be performed within 24 hours of presentation. It may provide other diagnoses if PE is excluded.
Echocardiogram may be useful in patients with PE large enough to cause cardiovascular collapse. It can detect right ventricular dilatation /raised pulmonary artery pressure or intracardiac thrombus.
DVT confirmed on ultrasound scan of leg veins can be used as a surrogate marker for PE. A negative scan does not exclude PE.
Thrombophilia screen should be performed in patients < 50 years of age with recurrent PE or a strong family history of proven DVT/PE.
Management:
LMWH should be given until PE is proven or excluded. Once PE is confirmed, patient should be started on warfarin and treatment should last for
– 3 months if it is a consequence of a clear precipitating event with no continuing risk factors
– 6 months for first idiopathic episode
– life-long for recurrent episodes or continuing major risk factors
Some patients are treated with LMWH instead of warfarin due to consideration of potential drug interactions e.g. patients with underlying malignancy undergoing chemotherapy.
Thrombolysis is indicated in massive PE with circulatory collapse. It may be life-saving in peri-arrest situations. A 50mg bolus of alteplase followed by 100mg over 2 hours is given.
5. Acute severe asthma
Assess severity
Acute severe asthma Life threatening asthma Near Fatal asthma
· PEF: 33-50% best/predicted h PEF <33% best/predicted hRaised paCO2
· Can’t complete sentences h SpO2 <92%
· Respiration >25 breaths/min h Silent chest/cyanosis/
· Pulse >110 beats/min poor respiratory effort
h Exhaustion/confusion/coma
h Measure arterial blood gases
0 High H+
0 PaO2 <8KPa [irrespective of oxygen treatment]
0 Normal PaCO2
Immediate treatment
· Oxygen: High flow (40-60%) ~ aim for SpO2 >92
· Nebulised salbutamol 5 mg + Nebulised ipratropium bromide 0.5 mg via oxygen-driven nebuliser, continue 4-6 hourly
· Prednisolone: 50 mg daily for at least 5 days or until recovery or IV hydrocortisone 100 mg 6 hourly if oral route not possible
If patient not improving within 15-30 min or Life threatening or Near fatal attack
· Discuss with middle grade/senior clinician
· Nebulised salbutamol: give every 15 minutes or continuously 10 mg hourly [Sidestream nebuliser]
· Add IV magnesium: 1.2-2g infusion over 20 minutes
· Other treatments: Middle grade/senior clinician may consider: IV salbutamol or IV aminophylline; alerting on-call anaesthetist
Discharge planning
· Check inhaler technique & assess adherence with therapy h Stop nebulised therapy 24 hrs before discharge
· Review chronic drug treatment h Written asthma action plan
· Smoking cessation advice h Respiratory clinic appointment in 4-6 wks
Monitoring/investigations
· Oximetry: maintain O2 >92%
· Repeat blood gases if :
- Initial paO2 <8>92%
- PCO2 normal or raised
· PEF
· Chest-ray: to exclude pneumothorax or pneumonia
6. ARDS – Acute Respiratory Distress Syndrome
ARDS is a disorder first described in 1967. It causes acute onset of respiratory distress, with severe breathlessness and hypoxia, often not improved by additional oxygen. Patients often become very sick very quickly and the majority of them will require to be ventilated in the intensive care unit.
ARDS can be diagnosed if the patient satisfies the following criteria
NAECC Criteria – North American and European Consensus Conference Criteria
· Known predisposing cause
· Acute onset
· Bilateral infiltrates on CXR
· Pulmonary artery occlusion pressure <18mmHg or no clinical signs heart
Failure
· PaO2/FiO2<200mmHg
ARDS can be caused by a variety of stimuli, not all of them act directly on the lung. These causes can be subdivided into direct (acting on the lung) and indirect (acting elsewhere) causes.
Direct - pneumonia
Pulmonary aspiration
Lung contusion
Fat embolism
Near drowning
Inhalational injury
Reperfusion injury
Indirect - non-pulmonary sepsis
Multiple trauma
Massive transfusion
Pancreatitis
Coronary bypass
Pathophysiology
ARDS causes pulmonary oedema due to damage to the alveolar-capillary membrane (not like heart failure, where the oedema is due to increased hydrostatic pressure). There is then a leak of fluid, proteins and inflammatory infiltrate (neutrophils, cytokines, proteases) into the alveolus. This fills the alveoli and makes them stiff and they are then unable to take part in gas exchange. This process can affect a variable proportion of the lung. This is why patient with ARDS are severely hypoxic, it is almost as though they are working on 1 lung or even less depending on the severity. Because the lung is so stiff, they often have difficulty taking big breaths and breath with rapid shallow breaths – another reason why they often need ventilated. All these changes can occur within 12-36 hours of the stimulating cause.
Epidemiology
The incidence of ARDS is variable but is about 5: 100 000. 20% of all patients who require ventilation in ICU fulfil the criteria for ARDS. You may not see it much on the wards as patients will often be so sick that they go straight from A&E or theatre to ICU so it is probably commoner than you think.
Mortality rate has not changed much in the last 30-40 years and is around 30-60% depending on cause and the premorbid health and age of the patient.
Only 10-15% of patients will die of respiratory failure. The others die of non-pulmonary organ failure, either because they are critically ill in some other way or because the severe hypoxia has damaged other organs. Of the patients who survive, most of them will regain full functional ability but a fair amount will have residual mildly deranged pulmonary function tests.
Treatment
As with any critically ill patient, general supportive management is very important from the outset. This includes:-
· Good nutrition
· Thromboembolism prophylaxis
· Gastric prophylaxis
· Careful fluid balance
In addition, the way patients are ventilated is also very important. The ARDSNet group published a paper in 2000 looking at a different way of ventilating patients and showed that this can reduce mortality by 22%. The change in strategy is due to the thinking that a large proportion of the lung is unable to take part in ventilation as the alveoli are full of ‘gunk’. Therefore, if we were to ventilate a lung normally, the unaffected lung would get a much greater tidal volume than it needs, stretching it and causing damage. The aim of the ventilation strategy is to do as little damage to the normal lung as possible, while aiming to try to ‘recruit’ as much of the damaged lung as we can and allow it to take part in ventilation.
This is done by:-
· Smaller tidal volumes – to reduce the chance of overdistension of normal lung
· Limiting the maximum pressure produced in the lungs
· Adding an additional pressure – PEEP – to hold open areas of lung which would otherwise collapse down
· Trying to decrease the amount of oxygen to <60% as soon as possible
· Tolerating a higher CO2 level than normal
Other treatments are tried now and again but none have been shown to produce any increase in survival rates. These include:-
· Prone ventilation – lying patients on their face to ventilate
· Inhaled nitric oxide
· ECMO – extra corporeal membrane oxygenation
· High dose steroids in chronic cases
Summary
Ø ARDS is a disorder causing acute onset respiratory distress, breathlessness and severe hypoxia due to a number of predisposing causes.
Ø Most patients will require ventilation in ICU.
Ø Mortality continues to remain high.
Ø Care and attention to general supportive management is very important.
Ø Patients with ARDS should be ventilated in a specific manner to avoid further lung damage.
Sunday, March 18, 2007
BABY CHECK
SIZE
Weight / Gestational Age / Plot Growth & Weight on Centile Chart
GENERAL OBSERVATION
Colour / Movement / Posture / Gross facies or dysmorphic features
CHEST
Do chest first... especially when baby is relaxed... otherwise difficult to listen to the chest..
Respiratory Rate (Put hand on the chest wall and count... comment: chest moves symmetricall, respi rate is.... per minute)
Auscultate Heart (heart sounds are normal)
ABDO + GENITALIA
Palpate abdomen
Liver / Spleen / Mass
Bowel sound
(Abdomen is soft and non-tender.. no masses felt.. but liver might be palpable subcostally sometimes... around 1 cm below the costal margin,
tip of the spleen may be felt too... then feel for left iliac fossa... if there are sort of 'masses' there.. must check for imperforate anus...)
Descended testes
(look... then comment... genitalia looks normal, testes are descended bilaterally)
FEMORAL PULSES
Present?
Equal?
Good volume?
(Coarctation of aorta --> reduced pulse pressure, PDA ---> increased pulse pressure)
PLANTAR REFLEX
Press on plantar arch (plantar reflex is present... up going or down going also okay both are normal...)
Number of toes?
HEAD
feel for fontanelle / sutures / head symmetry (comment.. fontanelle is soft and head is symmetrical)
Eyes, ears, nose, mouth (eyes, ears, nose and mouth are normal.. the upper 1/3 of the ears should be above the eye line... otherwise can say that there are low set ears)
Sucking reflex... then feel for palate with little finger.. any cleft palate/lip?
HANDS/PALMS
Count fingers...
Check.. for palmar crease... (single palmar crease may be present in normal babies)
Check for grasp reflex...
Then try to pull baby up to check for head lag... (can comment on the muscle tone and head lag..)
WHEN BABY IS HELD SITTING UP.....
do the Moro reflex...
Next... hold the baby up in ventral suspension
(comment... muscle tone is normal)
Check for midline.. run finger thru midline...
(comment: there are no tufts or pits along the midline)
Check for anus..
(comment: there is no imperforate anus)
Measure..Occipito-frontal circumference (get the biggest circumference... do 3 times... )
Red eye reflex (present... no cataract)
Hips
Barlow (bend and adduct knees, thumbs on midshaft of femur medially... middle fingers on the greater trochanter laterally.. try to dislocate hip/head of femur posteriorly and laterally)
Ortolani (bend and abduct knees, thumbs on midshaft of femur medially..
middle fingers on the greater trochanter laterally... try to push the head of the femur back into position... anteriorly and medially...)
NB: leave the measurement of the OFC , red reflex and hip dislocation tests at the end.. as they are uncomfortable...
The baby is NORMAL... yay!!!!
SIZE
Weight / Gestational Age / Plot Growth & Weight on Centile Chart
GENERAL OBSERVATION
Colour / Movement / Posture / Gross facies or dysmorphic features
CHEST
Do chest first... especially when baby is relaxed... otherwise difficult to listen to the chest..
Respiratory Rate (Put hand on the chest wall and count... comment: chest moves symmetricall, respi rate is.... per minute)
Auscultate Heart (heart sounds are normal)
ABDO + GENITALIA
Palpate abdomen
Liver / Spleen / Mass
Bowel sound
(Abdomen is soft and non-tender.. no masses felt.. but liver might be palpable subcostally sometimes... around 1 cm below the costal margin,
tip of the spleen may be felt too... then feel for left iliac fossa... if there are sort of 'masses' there.. must check for imperforate anus...)
Descended testes
(look... then comment... genitalia looks normal, testes are descended bilaterally)
FEMORAL PULSES
Present?
Equal?
Good volume?
(Coarctation of aorta --> reduced pulse pressure, PDA ---> increased pulse pressure)
PLANTAR REFLEX
Press on plantar arch (plantar reflex is present... up going or down going also okay both are normal...)
Number of toes?
HEAD
feel for fontanelle / sutures / head symmetry (comment.. fontanelle is soft and head is symmetrical)
Eyes, ears, nose, mouth (eyes, ears, nose and mouth are normal.. the upper 1/3 of the ears should be above the eye line... otherwise can say that there are low set ears)
Sucking reflex... then feel for palate with little finger.. any cleft palate/lip?
HANDS/PALMS
Count fingers...
Check.. for palmar crease... (single palmar crease may be present in normal babies)
Check for grasp reflex...
Then try to pull baby up to check for head lag... (can comment on the muscle tone and head lag..)
WHEN BABY IS HELD SITTING UP.....
do the Moro reflex...
Next... hold the baby up in ventral suspension
(comment... muscle tone is normal)
Check for midline.. run finger thru midline...
(comment: there are no tufts or pits along the midline)
Check for anus..
(comment: there is no imperforate anus)
Measure..Occipito-frontal circumference (get the biggest circumference... do 3 times... )
Red eye reflex (present... no cataract)
Hips
Barlow (bend and adduct knees, thumbs on midshaft of femur medially... middle fingers on the greater trochanter laterally.. try to dislocate hip/head of femur posteriorly and laterally)
Ortolani (bend and abduct knees, thumbs on midshaft of femur medially..
middle fingers on the greater trochanter laterally... try to push the head of the femur back into position... anteriorly and medially...)
NB: leave the measurement of the OFC , red reflex and hip dislocation tests at the end.. as they are uncomfortable...
The baby is NORMAL... yay!!!!
Thursday, March 15, 2007
DEVELOPMENT IN THE FIRST YEAR OF LIFE
NEWBORN
1.Gross Motor and Posture
In a prone position, the head is shown turned to the side, and the arms are close to the chest with the elbows fully flexed. The hips and knees are flexed under the buttocks. Note that the hands are tightly closed.
In a supine position, the baby is lying in a flexed position, and the ahnds are now open. Continual fisting at this age is always abnormal.
On ventral suspension, the head droops below the plane of the body, the hips are fully flexed and the limbs hang down,
When pulled to sit (baby is shown at 10 days), take note of the marked head lag.
2.Vision and Fine Motor
The baby is shown fixating on the mother's face.
* Moro Reflex... While the head is held in the examiner's hands, a sudden extension of the neck results in abduction and extension of the arms with extension of the fingers, and subsequent flexion of the fingers and arms which are then adducted. The symmetric Moro reflex requires the head to lie in the midline.
6-8 WEEKS
1. Gross Motor and Posture
In prone position, the pelvis is flatm and the arms are flexed with the elbows away from the body. The hips are more extended than previously, and the chin is off the couch.
In supine position, the baby's arms are slightly flexed, the knees are apart and the soles of the feet are facing upward. Note that there is no assymetry.
On ventral suspension, the head is in the same plane as the body, and the hips are extended.
On 'standing', the baby is shown standing with his body straighteneed. Take note of the position of the extended legs, with the weight on the feet and no scissoring (adductor spasm).
Primitive Reflexes..
Rooting Reflex
Gentle stimulation of the cheek causes the baby to turn to suck. Two important features here... a good suckling response and a red retinal reflex.
Grasp Reflex
The grasp reflex may be elicited in the hands or the feet. Note the strength of the grip.
Asymmetric Tonic Neck Reflexes (ATNR)
Lateral turning of the head results in extension of the arm on the same side, with flexion of the limbs on the oposite side ('fencing' position). Persistence of this reflex beyond 4 months is abnormal. Occasionally, the reflex is absent at birth but is present by the end of the first month.
Walking / placing reflex
Stimulation of the dorsal aspect of the foot results in walking movements.
2. Vision and Fine Motor
In the supine position, the baby fixes on and follows the movement of a toy horizontally through an angle of 180 degrees. To elicit this response, use a bright red ball held 50cm from the baby's eyes.
3. Hearing..
may be assessed by parental questionnaire. At-risk babies should be referred to expert audiological opinion.
4. Social Interaction//
is observed as consolability and smiling, which is nearly always present by 6 weeks.
NEWBORN
1.Gross Motor and Posture
In a prone position, the head is shown turned to the side, and the arms are close to the chest with the elbows fully flexed. The hips and knees are flexed under the buttocks. Note that the hands are tightly closed.
In a supine position, the baby is lying in a flexed position, and the ahnds are now open. Continual fisting at this age is always abnormal.
On ventral suspension, the head droops below the plane of the body, the hips are fully flexed and the limbs hang down,
When pulled to sit (baby is shown at 10 days), take note of the marked head lag.
2.Vision and Fine Motor
The baby is shown fixating on the mother's face.
* Moro Reflex... While the head is held in the examiner's hands, a sudden extension of the neck results in abduction and extension of the arms with extension of the fingers, and subsequent flexion of the fingers and arms which are then adducted. The symmetric Moro reflex requires the head to lie in the midline.
6-8 WEEKS
1. Gross Motor and Posture
In prone position, the pelvis is flatm and the arms are flexed with the elbows away from the body. The hips are more extended than previously, and the chin is off the couch.
In supine position, the baby's arms are slightly flexed, the knees are apart and the soles of the feet are facing upward. Note that there is no assymetry.
On ventral suspension, the head is in the same plane as the body, and the hips are extended.
On 'standing', the baby is shown standing with his body straighteneed. Take note of the position of the extended legs, with the weight on the feet and no scissoring (adductor spasm).
Primitive Reflexes..
Rooting Reflex
Gentle stimulation of the cheek causes the baby to turn to suck. Two important features here... a good suckling response and a red retinal reflex.
Grasp Reflex
The grasp reflex may be elicited in the hands or the feet. Note the strength of the grip.
Asymmetric Tonic Neck Reflexes (ATNR)
Lateral turning of the head results in extension of the arm on the same side, with flexion of the limbs on the oposite side ('fencing' position). Persistence of this reflex beyond 4 months is abnormal. Occasionally, the reflex is absent at birth but is present by the end of the first month.
Walking / placing reflex
Stimulation of the dorsal aspect of the foot results in walking movements.
2. Vision and Fine Motor
In the supine position, the baby fixes on and follows the movement of a toy horizontally through an angle of 180 degrees. To elicit this response, use a bright red ball held 50cm from the baby's eyes.
3. Hearing..
may be assessed by parental questionnaire. At-risk babies should be referred to expert audiological opinion.
4. Social Interaction//
is observed as consolability and smiling, which is nearly always present by 6 weeks.
Tuesday, March 13, 2007
Describe the features you would note in examining a lump/an ulcer. How would these features help in your differential diagnoses.
LUMP
Look:
Feel:
Press:
Move:
Transilluminate:
Surrounding Tissues:
ULCERS
Look
Feel
Surrounding Tissues
* expansile pulsation = fingers pushed apart
* transmitted pulsation = fingers pushed in same direction
* compressible = lump disappears on pressure and reappears on release
* reducible = lump reappears only on application of another force, e.g. coughing, gravity
* fluctuant = two fingers move apart when middle area pressed (test for a small lump)
* fluid thrill (use for large swelling)
LUMP
Look:
- Inspect (shape, colour)
- Measure (position, size)
Feel:
- Temperature (warm?)
- Surface (smooth, rough, bosselated)
- Edge (clearly/poorly defined)
- Consistency (stony-hard, rubbery-hard, spongy, soft)
- Surrounding area (indurated)
Press:
- Pulsatility (expansile pulsation, transmitted pulsation)*
- Compressibility/reducibility*
- Percussion (resonant/dull)
- Fluctuation/fluid thrill*
Move:
- Skin over lump (fixation)
- In 2 planes at right angles to each other (mobility)
- Tense underlying muscle (attachment to underlying muscle)
Listen:
- Bruit/bowel sounds
Transilluminate:
- transilluminable
Surrounding Tissues:
- Regional lymph nodes (local lymphadenopathy)
- Sensation (neurological deficit)
- Power (weakness)
ULCERS
Look
- Measure (position, size, shape)
- Base (colour: red/granulation tissue, penetration: tendon/bone/blood/pus)
- Edge (sloping/punched out/undermined/raised/raised and everted)
- Depth
Feel
- Tender?
- Temperature
Surrounding Tissues
- Regional lymph nodes (lymphadenopathy)
- Sensation (local neurological deficit)
- Power
* expansile pulsation = fingers pushed apart
* transmitted pulsation = fingers pushed in same direction
* compressible = lump disappears on pressure and reappears on release
* reducible = lump reappears only on application of another force, e.g. coughing, gravity
* fluctuant = two fingers move apart when middle area pressed (test for a small lump)
* fluid thrill (use for large swelling)
Sunday, February 04, 2007
Date of Visit:________
MANAGEMENT OF THE SICK CHILD AGE 2 MONTHS UP TO 5 YEARS
§ Name:
§ Age:
§ Weight: __kg
§ Temperature: __ °C
§ ASK: What are the child’s problems?
Initial visit?
Follow-up vist?
CHECK FOR GENERAL DANGER SIGNS
§ Not able to drink or breastfeed
§ Vomits everything
§ Convulsion during illness
§ Lethargic or unconscious
§ Convulsing now
DOES THE CHILD HAVE COUGH OR DIFFICULT BREATHING?
§ For how long? __ Days
§ Count the breaths in on minute. __ breaths per minute. Fast breathing?
§ Look for chest indrawing
§ Look and listen for stridor
§ Look and listen for wheeze
DOES THE CHILD HAVE DIARRHOEA?
§ For how long? __ Days
§ Is there blood in the stools?
§ Look at the child’s general condition.Is the child:
o Lethargic and unconscious
o Restless or irritable
§ Look for sunken eyes.
§ Offer the child fluid. Is the child:
o Not able to drink or drinking poorly?
o Drinking eagerly, thirsty?
§ Skin tugor:Pinch the skin of the abdomen. Does it go back:
o Very slowly (longer than 2 seconds)?
o Slowly?
DOES THE CHILD HAVE FEVER? (by history/temperature 37.5°C or above)
§ For how long? __ Days
§ If more than 7 days, has fever been present every day?
§ Has child had measles within the last three months?
BSMP Positive / Negative / Not done / Falciparum / Vivax
§ Look or feel for stiff neck
§ Look for runny nose
Look for signs of MEASLES:
§ Generalized rash and
§ One of these: cough, runny nose, or red eyes
If the child has measles now or within the last 3 months:
§ Look for mouth ulcers .
§ If yes, are they deep or extensive?
§ Look for pus draining from the eye.
§ Look for clouding of the cornea
DOES THE CHILD HAVE EAR PROBLEM?
§ Is there ear pain?
§ Is there ear discharge?
§ If Yes, for how long? __ Days
§ Pain in ear when touched.
§ Look for pus draining from the ear.
§ Feel for tender swelling behind the ear.
THEN CHECK FOR MALNUTRITION AND ANAEMIA
§ Look for visible severe wasting.
§ Look for palmar pallor
o Severe palmar pallor? Some palmar pallor?
§ Look and feel for oedema of both feet.
§ Determine weight for age.
§ Very Low? Not Very Low?
CHECK THE CHILD’S IMMUNIZATION STATUS
ASSESS CHILD’S FEEDING if child has ANAEMIA OR VERY LOW WEIGHT or is less than 2 years old.
§ Do you breastfeed your child? Yes__ No__
o If Yes, how many times in 24 hours? __ times.
§ Do you breastfeed during the night? Yes__ No__
o If Yes, what food or fluids? _________
§ How many times per day? __ time. What do you use to feed the child? _________
§ If very low weight for age: How large are servings? _________Does the child receive his own serving? __ Who feeds the child and how? _________During the illness, has the child’s feeding changed? Yes__ No__
o If Yes, how?
ASSESS OTHER PROBLEMS:
MANAGEMENT OF THE SICK CHILD AGE 2 MONTHS UP TO 5 YEARS
§ Name:
§ Age:
§ Weight: __kg
§ Temperature: __ °C
§ ASK: What are the child’s problems?
Initial visit?
Follow-up vist?
CHECK FOR GENERAL DANGER SIGNS
§ Not able to drink or breastfeed
§ Vomits everything
§ Convulsion during illness
§ Lethargic or unconscious
§ Convulsing now
DOES THE CHILD HAVE COUGH OR DIFFICULT BREATHING?
§ For how long? __ Days
§ Count the breaths in on minute. __ breaths per minute. Fast breathing?
§ Look for chest indrawing
§ Look and listen for stridor
§ Look and listen for wheeze
DOES THE CHILD HAVE DIARRHOEA?
§ For how long? __ Days
§ Is there blood in the stools?
§ Look at the child’s general condition.Is the child:
o Lethargic and unconscious
o Restless or irritable
§ Look for sunken eyes.
§ Offer the child fluid. Is the child:
o Not able to drink or drinking poorly?
o Drinking eagerly, thirsty?
§ Skin tugor:Pinch the skin of the abdomen. Does it go back:
o Very slowly (longer than 2 seconds)?
o Slowly?
DOES THE CHILD HAVE FEVER? (by history/temperature 37.5°C or above)
§ For how long? __ Days
§ If more than 7 days, has fever been present every day?
§ Has child had measles within the last three months?
BSMP Positive / Negative / Not done / Falciparum / Vivax
§ Look or feel for stiff neck
§ Look for runny nose
Look for signs of MEASLES:
§ Generalized rash and
§ One of these: cough, runny nose, or red eyes
If the child has measles now or within the last 3 months:
§ Look for mouth ulcers .
§ If yes, are they deep or extensive?
§ Look for pus draining from the eye.
§ Look for clouding of the cornea
DOES THE CHILD HAVE EAR PROBLEM?
§ Is there ear pain?
§ Is there ear discharge?
§ If Yes, for how long? __ Days
§ Pain in ear when touched.
§ Look for pus draining from the ear.
§ Feel for tender swelling behind the ear.
THEN CHECK FOR MALNUTRITION AND ANAEMIA
§ Look for visible severe wasting.
§ Look for palmar pallor
o Severe palmar pallor? Some palmar pallor?
§ Look and feel for oedema of both feet.
§ Determine weight for age.
§ Very Low? Not Very Low?
CHECK THE CHILD’S IMMUNIZATION STATUS
ASSESS CHILD’S FEEDING if child has ANAEMIA OR VERY LOW WEIGHT or is less than 2 years old.
§ Do you breastfeed your child? Yes__ No__
o If Yes, how many times in 24 hours? __ times.
§ Do you breastfeed during the night? Yes__ No__
o If Yes, what food or fluids? _________
§ How many times per day? __ time. What do you use to feed the child? _________
§ If very low weight for age: How large are servings? _________Does the child receive his own serving? __ Who feeds the child and how? _________During the illness, has the child’s feeding changed? Yes__ No__
o If Yes, how?
ASSESS OTHER PROBLEMS:
Date of Visit:________
MANAGEMENT OF THE SICK YOUNG INFANT AGE 1 WEEK UP TO 2 MONTHS
§ Name:
§ Age:
§ Weight: __kg
§ Temperature: __ °C
§ ASK: What are the infant’s problems?
Initial visit?
Follow-up vist?
CHECK FOR POSSIBLE BACTERIAL INFECTION
§ Has the infant had convulsions?
§ Count the breaths in one minute. ___ breaths per minute
o Repeat if elevated. ___ Fast breathing?
§ Look for severe chest indrawing
§ Look for nasal flaring
§ Look and feel for bulging fontanelle
§ Look for pus draining from the ear
§ Look at umbilicus. Is it red or draining pus?
o Does the redness extend to the skin?
§ Fever (temperature 37.5°C or feels hot) or low body temperature (below 35.5°C or feels cold)
§ Look for skin pustules. Are there many or severe pustules?
§ See if young infant is lethargic or unconscious
§ Look at the young infant’s movements. Less than normal?
DOES THE YOUNG INFANT HAVE DIARRHOEA?
§ For how long? ___ Days
§ Is there blood in the stools?
§ Look at the young infant’s general condition. Is the infant:
o Lethargic or unconscious?
o Restless and irritable?
§ Look for sunken eyes
§ Pinch the skin of the abdomen. Does it go back:
o Very slowly (longer than 2 seconds)?
o Slowly?
THEN CHECK FOR FEEDING PROBLEM OR LOW WEIGHT
§ Is there any difficulty feeding? Yes__ No__
§ Is the infant breastfed? Yes __ No__
§ If Yes, how many times in 24 hours? __ Times
§ Does the infant usually receive any other foods or drinks? Yes__ No__
§ If Yes, how often?
§ What do you use to feed the child?
§ Determine weight for age. Low__ Not Low__
If the infant has any difficulty feeding, is feeding less than 8 times in 24 hours, is taking any other food or drinks, or is low weight for age AND has no indications to refer urgently to hospital:
ASSESS BREASTFEEDING:
§ Has the infant breastfed in the previous hour?
§ If infant has not fed in the previous hour, ask the mother to put her infant to the breast. Observe breastfeed for 4 minutes.
§ Is the infant able to attach? To check attachment, look for:
o Chin touching breast
o Mouth wide open
o Lower lip turned outward
o More areola above than below the mouth
no attachment at all not well attached good attachment
§ Is the infant suckling effectively (that is, slow deep sucks, sometimes pausing)?
not suckling at all not suckling effectively suckling effectively
§ Look for ulcers or white patches in the mouth (thrush)
CHECK THE YOUNG INFANT’S IMMUNIZATION STATUS
ASSESS FOR OTHER PROBLEMS:
MANAGEMENT OF THE SICK YOUNG INFANT AGE 1 WEEK UP TO 2 MONTHS
§ Name:
§ Age:
§ Weight: __kg
§ Temperature: __ °C
§ ASK: What are the infant’s problems?
Initial visit?
Follow-up vist?
CHECK FOR POSSIBLE BACTERIAL INFECTION
§ Has the infant had convulsions?
§ Count the breaths in one minute. ___ breaths per minute
o Repeat if elevated. ___ Fast breathing?
§ Look for severe chest indrawing
§ Look for nasal flaring
§ Look and feel for bulging fontanelle
§ Look for pus draining from the ear
§ Look at umbilicus. Is it red or draining pus?
o Does the redness extend to the skin?
§ Fever (temperature 37.5°C or feels hot) or low body temperature (below 35.5°C or feels cold)
§ Look for skin pustules. Are there many or severe pustules?
§ See if young infant is lethargic or unconscious
§ Look at the young infant’s movements. Less than normal?
DOES THE YOUNG INFANT HAVE DIARRHOEA?
§ For how long? ___ Days
§ Is there blood in the stools?
§ Look at the young infant’s general condition. Is the infant:
o Lethargic or unconscious?
o Restless and irritable?
§ Look for sunken eyes
§ Pinch the skin of the abdomen. Does it go back:
o Very slowly (longer than 2 seconds)?
o Slowly?
THEN CHECK FOR FEEDING PROBLEM OR LOW WEIGHT
§ Is there any difficulty feeding? Yes__ No__
§ Is the infant breastfed? Yes __ No__
§ If Yes, how many times in 24 hours? __ Times
§ Does the infant usually receive any other foods or drinks? Yes__ No__
§ If Yes, how often?
§ What do you use to feed the child?
§ Determine weight for age. Low__ Not Low__
If the infant has any difficulty feeding, is feeding less than 8 times in 24 hours, is taking any other food or drinks, or is low weight for age AND has no indications to refer urgently to hospital:
ASSESS BREASTFEEDING:
§ Has the infant breastfed in the previous hour?
§ If infant has not fed in the previous hour, ask the mother to put her infant to the breast. Observe breastfeed for 4 minutes.
§ Is the infant able to attach? To check attachment, look for:
o Chin touching breast
o Mouth wide open
o Lower lip turned outward
o More areola above than below the mouth
no attachment at all not well attached good attachment
§ Is the infant suckling effectively (that is, slow deep sucks, sometimes pausing)?
not suckling at all not suckling effectively suckling effectively
§ Look for ulcers or white patches in the mouth (thrush)
CHECK THE YOUNG INFANT’S IMMUNIZATION STATUS
ASSESS FOR OTHER PROBLEMS:
Screening tests for antenatal diagnosis
Maternal blood for....
- blood group + Rh antibodies
- Hep B
- Syphilis
- Rubella
- HIV (after counselling and maternal consent)
- neural tube defects
- Down's syndrome
Ultrasound screening for ....
- gestational age - if performed before 20/52
- multiple pregnancies
- structural abnormalities
- fetal growth monitoring - abdo + head circumference and femur length
- amniotic fluid volume
- oligohydramnios (reduced fetal urine production - dysplastic /absent kidneys or obstructive uropathy, prolonged rupture of membranes -> IUGR) --> Pulmonary hypoplasia and limb + facial deformities from pressure on fetus (Potter's Sx)
- polyhydramnios (assoc. with maternal diabetes & fetal G.I. atresia)
Techniques for antenatal diagnosis
- Detailed Ultrasound - structural malformations
- Amniocentesis - chromosomal analysis, Alphafetoprotein+acetylcholinesterase (NTD), bilirubin estimation (rhesus disease), enzyme analysis (inborn errorof metabolism)
- Transabdominal chorionic villus sample - chromosomal analysis, enzyme analysis (inborn error of metabolism), DNA analysis (thalassaemia, haemophilia A+B, CF, Duchenne's)
- Fetal blood sample - rapid chromosomal anaylsis (fetal malformations or severe IUGR), assessment of severe rhesus & platelet isoimmunisation, congenital infectoin serology
- Fetal tissue sampling - skin biopsy (severe congenital skin disorders)
Pre-Pregnancy Care
Counselling on...
Counselling on...
- smoking - reduced birth wt, increase risk of miscarriage, SIDS
- medication - teratogenic effects
- alcohol xs - fetal damage
- congenital rubella - immunisation b4 pregnancy
- exposure to toxoplasmosis - avoid undercooked meat, wear gloves when handling cat litter
- listeria infection - from unpasteurised dairy products
- liver - best avoided; high[ vitamin A]
- pre-pregnancy folic acid supplements - reduce risk of NTD
Risk of fetal abnormality increases with...
- mother > 35, Down's Sx > 1 in 380
- previous abnormal child
- family history of inherited disorder
- parents = cariers of autosomal recessive disorder e.g. thalassaemia
- parents carry chromosomal rearrangement
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