Category: Respiratory

May 5, 2021

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)

April 19, 2021

Scombroid Poisoning- NOT another fishy allergy

Scombroid poisoning (AKA – Histamine fish poisoning) is apparently more common than we think and accounts for 40% of seafood related illness in the USA according to the CDC. But Scombriod poisoning is missed as its put down to allergy. Read more

April 9, 2021

COVID-19 Vaccine Induced Thrombosis/Thrombocytopenia (VITT)

Inclusion Criteria [Both of]:

Received AstraZeneca (AZ) COVID 19 vaccination within 42 days (typically 5-42 days from immunisation)
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)

Received AZ COVID 19 vaccination within 42 days
New Onset thrombocytopenia (PLTs <150×109/L)
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

Anaphylaxis

Not all Allergies are Anaphylaxis!

Anaphylaxis is defined as:

Severe life-threatening systemic hypersensitivity reaction
Where BOTH of the following criteria are met:

1. Sudden onset & rapid progression
2. Life-threatening compromise of ONE or MORE of: Airway/Breathing/Circulation

April 3, 2021

Pneumothorax – Medical ones

To drain or not to drain? – that is the question (Follow the BTS algorithm).This is not for Tension! Read more

March 14, 2021

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.