Category: Respiratory

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 Tinzaparin/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.

Read more

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

Read more

Pneumonia (Community Acquired)

Severe Pneumonia: Please Request/Send – Samples Sputum/Blood/Urine

BTS Definition of CAP

Signs of acute Lower Respiratory Tract illness (LRTI) [Cough] &:

  •  ≥1 other LRTI Symptom [Pleuritic pain, Tachypnea, Dyspnea, etc]
  • New Focal Chest Signs [Creps, Bronchial breathing, Red. A/E]
  • ≥1 Systemic sign [Fever, Sweats, Chills, Rigors, >38oC]
  • New CXR changes [if hospitalized]

Read more

CPAP Set-Up

NIPPV 3 machines are used throughout the trust to deliver NIV and CPAP – and should be commenced in ED if transfer to ward/ICU is adding significant delay

  • NIV/CPAP  is NOT an Aerosol Generating Proceedure (AGP) [as of Sept 2022]
  • CPAP/EPAP levels of 8-15cmH2O

This video demonstrates how to set up CPAP on the NIPPV 3

 

COPD – exacerbations

COPD patients vary widely, due to their comorbidities, social circumstances, and wishes. So choosing the best treatment pathway for the patient can be complex. Involve senior decision makers.

Questions

  • Is hospital the best place for them?
  • Do they need NIV?
  • Are they dying? – would you want to die surrounded by strangers or with your family?

Read more