Category: Respiratory

NIV (Non Invasive Ventilation)

NIV should be considered for use in patients with a  persisting Acute Hypercapnic Respiratory Failures after a maximum of one hour of standard medical therapy.

  • Complete the Ad-hoc form
  • Increase pressures from Initial 12/5 cmH2O to 20/5cmH2O – as tolerated over 1st hour

However, ICU should be contacted early if the patient has one of the following:

  • Asthma – Intubation the option of choice in Life threatening
  • Pneumonia – NIV should only be considered as a bridge to intubation
  • No pre-exisiting respiratory issue – NIV not likely helpful
  • pH <7.25 (low threshold for ICU input)
  • pCO2 >6.5kPa (low threshold for ICU input)
  • Type 1 Respiratory Failure (low threshold for ICU input)

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COVID-19 Vaccine Induced Thrombosis/Thrombocytopenia (VITT)

Inclusion Criteria [Both of]:

  1. Received AstraZeneca (AZ) COVID 19 vaccination within 42 days (typically 5-42 days from immunisation)
  2. New Onset thrombocytopenia (PLTs <150×109/L) – with or without Thrombosis
    • 5% of cases have had a “Normal” Platelet count at presentation
      • High index of suspicion repeat bloods next day
      • ‘High index of suspicion’ in this context is day 5- 28 post AZ vaccine with new onset headache or abdominal pain which is atypical and severe in nature.

Initial Investigations:

  • FBC– specifically to confirm thrombocytopenia <150x 109/L
  • Coagulation screen and D Dimers
  • Blood film to confirm true thrombocytopenia and identify alternative causes

PROBABLE CASE: (ALL 3 criteria)

  1. Received AZ COVID 19 vaccination within 42 days
  2. New Onset thrombocytopenia (PLTs <150×109/L)
  3. D Dimers > 2000 mcg/L

URGENT Scan to confirm the suspected clot.

[If patient doesn’t fit “PROBABLE CASE” proceed to usual treatment]


Condition specific advice:

Central clot:

  • inc. Cerebral Venous Sinus Thrombosis (CVST), Pulmonary Embolis (PE), Splenic, Proximal DVT
  • Discuss with Haematologist
  • Admit Medicine

Suspected DVT (scan unavailable):

  • Treat with Rivaroxaban (Do Not use Dalteparin/LMWH)
  • Request Ultrasound
  • Return AAU Next Day
  • Safety-net Advice

Confirmed Distal DVT (Not above inguinal ligament)

  • Platelets  <100×109/L – Discus with Haematology
  • Platelets ≥100×109/L – Treat as normal

Thrombocytopenia only

  • Platelets  <100×109/L – Discus with Haematology
  • Platelets ≥100×109/L – Treat as normal

Treatment (will be directed by Haematology & Specialist teams):

Avoid:

  • Heparin Based anticoagulants
  • Antiplatelets
  • Platelet Transfusion

May Require:

  • IV immunoglobulin
  • Steroid
  • Anticoagulation with: DOAC, Fondaparinux, Argatroban

Further reading

 

Pulmonary Embolism – PE

PE is somehow both the most over and under diagnosed condition. with severity ranging from the questionable sub-segmental PE to the Massive PE (an indication for thrombolysis). So think:

  • Does this presentation sound like a PE? – If not STOP here
  • Pregnant?  – Click Here
  • Do you think this is likely a PE? (if so you can’t use PERC)
  • Does D-Dimer answer  your question? (whats the Wells)
  • Massive PE  – think Thrombolysis
  • Sub-Massive PE – there is lots of debate (involve seniors), locally needs 2 consultant sign off and not considered time critical.

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Methaemoglobinaemia

Q: Why are Smurf’s Blue? 

A: Methaemoglobin (MetHb) of course!

MetHb is produced by oxidisation of the Iron in Haemoglobin (Hb) from Fe2+ to Fe3+

Fe3+ prevents Hb carrying oxygen (thus produces symptoms of hypoxia)

Often due to chemical ingestion, but may also be genetic

Treated with Methyl Blue & supportive measures

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