1. Dr Jack Bond Clinical Teaching Fellow Nov 2011
Acute Medical Cases
Dr Jack Bond
Clinical Teaching Fellow
Nov 2011

2. Aims To introduce you to the presentation and initial management of:
Obstructive airways disease
Acute kidney injury
GI bleed

3. Group work Divide into groups of 4-6 Each group given a case
Spend 10 minutes working through the case
Select a member of your group to present the case and management back to the whole group

4. COPD - Objectives Be able to diagnose COPD
Describe the initial management of COPD exacerbation
List the indications/contraindications for NIV
Understand set up and monitoring of NIV
List complications associated with NIV

5. Case 1
A 75 year old man attends his GP with breathlessness over the last 6 months. He has been coughing up phlegm most days for the last few months, but worse over the last few days. He has smoked 20 cigarettes a day for the past 30 years.
On examination, sats are 93% on air, RR 24, temp 38.3, BP 124/75, HR 85. The chest shows widespread wheeze throughout.

6. Case 1
1. List your differential diagnosis
2. what diagnostic tests would confirm a diagnosis of chronic obstructive pulmonary disease?
3. How would you assess severity of COPD?
4. in A+E, what would be your initial management of this patient?

7. COPD - Background
COPD is predominantly caused by smoking and is characterised by airflow obstruction that:
- is not fully reversible
- does not change markedly over several months
- is usually progressive in the long term
NOTES FOR PRESENTER:
The airflow obstruction is present because of a combination of airway and parenchymal damage. The damage is the result of chronic inflammation that differs from that seen in asthma and which is usually the result of tobacco smoke. Significant airflow obstruction may be present before the person is aware of it.
COPD produces symptoms, disability and impaired quality of life which may respond to pharmacological and other therapies that have limited or no impact on the airflow obstruction.
COPD is now the preferred term for the conditions in patients with airflow obstruction who were previously diagnosed as having chronic bronchitis or emphysema.
11/21/2011

8. Diagnose COPD over 35, and smokers or ex-smokers, and
have any of these symptoms:
- exertional breathlessness
- chronic cough
- regular sputum production,
frequent winter ‘bronchitis’
Wheeze
And no clinical features of asthma
NOTES FOR PRESENTERS:
Key points to raise:
Please refer your audience to page 6 of the QRG which shows the algorithm to support the diagnosis recommendation.
Recommendation in full:
A diagnosis of COPD should be considered in patients over the age of 35 who have a risk factor (generally smoking) and who present with one or more of the following symptoms:
exertional breathlessness
chronic cough
regular sputum production
frequent winter ‘bronchitis’
wheeze. [ ]
Related recommendations:
COPD and asthma are frequently distinguishable on the basis of history (and examination) in untreated patients presenting for the first time. Features from the history and examination (see page 6 of the QRG) should be used to differentiate COPD from asthma whenever possible. [ ]
[2004]

9. Differentiating COPD from asthma
Clinical features
COPD
Asthma
Smoker or ex-smoker
Nearly all
Possibly
Symptoms under age 35
Rare
Often
Chronic productive cough
Common
Uncommon
Breathlessness
NOTES FOR PRESENTERS:
Recommendations in full:
COPD and asthma are frequently distinguishable on the basis of history (and examination) in untreated patients presenting for the first time. Features from the history and examination (such as those listed in table 3) should be used to differentiate COPD from asthma whenever possible. [ ]
Longitudinal observation of patients (whether using spirometry, peak flow or symptoms) should also be used to help differentiate COPD from asthma. [ ]
Persistent and progressive
Variable
Night time waking with breathlessness and or wheeze
Uncommon
Common
Significant diurnal or day to day variability of symptoms
uncommon
Common
11/21/2011
[2004]

10. Differentiating COPD from asthma: 2
If diagnostic uncertainty remains:-
- FEV1 and FEV1/FVC ratio return to normal with drug therapy
- a very large (>400ml) FEV1 response to bronchodilators or to 30mg prednisolone daily for 2 weeks
- serial peak flow measuremenst showing significant (20% or greater) diurnal or day-to-day variability
[2004]
NOTES FOR PRESENTERS:
Recommendations in full:
Longitudinal observation of patients (whether using spirometry, peak flow or symptoms) should also be used to help differentiate COPD from asthma. [ ]
To help resolve cases where diagnostic doubt remains, or both COPD and asthma are present, the following findings should beused to help identify asthma:
- a large (> 400 ml) response to bronchodilators
- a large (> 400 ml) response to 30 mg oral prednisolone daily for 2 weeks
- serial peak flow measurements showing 20% or greater diurnal or day-to-day variability.
Clinically significant COPD is not present if the FEV1 and FEV1/FVC ratio return to normal with drug therapy. [ ]
If diagnostic uncertainty remains, referral for more detailed investigations, including imaging and measurement of TLCO, should be considered. [ ]
Related recommendation:
If patients report a marked improvement in symptoms in response to inhaled therapy, the diagnosis of COPD should be reconsidered. [ ]

11. Diagnose COPD: assessment of severity
Assess severity of airflow obstruction using reduction in FEV1
NICE clinical guideline 12 (2004)
ATS/ERS 2004
GOLD 2008
NICE clinical guideline 101 (2010)
Post-bronchodilator FEV1/FVC
FEV1 % predicted
Post-bronchodilator
Post-bronchodilator
Post-bronchodilator
< 0.7
80%
Mild
Stage 1 (mild)
Stage 1 (mild)*
NOTES FOR PRESENTERS:
Key points to raise:
Disability in COPD can be poorly reflected in the FEV1. A more comprehensive assessment also includes:
- degree of airflow obstruction and disability
- frequency of exacerbations
- prognostic factors such as breathlessness (assessed using the Medical Research Council [MRC] scale), carbon monoxide lung transfer factor [TLCO], health status, exercise capacity, BMI, partial pressure of oxygen in arterial blood [PaO2] and cor pulmonale. [adapted from ]
Investigate symptoms that seem disproportionate to the spirometric impairment using a CT scan or TLCO testing.
Calculate the BODE index (BMI, airflow obstruction, dyspnoea and exercise capacity) to assess prognosis (where the component information is currently available).
Assess severity of airflow using the table on the slide.
Recommendation in full:
The severity of airflow obstruction should be assessed according to the reduction in FEV1 as shown in table on the slide [ ]
Abbreviations:
ATS, American Thoracic Society; ERS, European Respiratory Society; FVC, forced vital capacity; GOLD, Global Initiative for Chronic Obstructive Lung Disease
References :
Quanjer PH, Tammeling GJ, Cotes et al. (1993) Lung Volumes and forced ventilatory flows. Report Working Party Standardization of Lung Function Tests, European Community for Steel and Coal. Official Statement of the European Respiratory Society. European Respiratory Journal (Suppl) 16:5-40.
Celli BR, MacNee W (2004) Standards for the diagnosis and treatment of patients with COPD: a summary of the ATS/ERS position Paper. European Respiratory Journal 23(6):
Global Initiative for Chronic Obstructive Lung Disease (GOLD) Global Strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease.
< 0.7
50–79%
Mild
Moderate
Stage 2 (moderate)
Stage 2 (moderate)
< 0.7
30–49%
Moderate
Severe
Stage 3 (severe)
Stage 3 (severe)
< 0.7
< 30%
Severe
Very severe
Stage 4 (very severe)**
Stage 4 (very severe)**
* Symptoms should be present to diagnose COPD in people with mild airflow obstruction
** Or FEV1 < 50% with respiratory failure
11/21/2011
[new 2010]

12. 4 year survival 0-2 Points: 80% 3-4 Points: 67% 5-6 Points: 57%
11/21/2011

13. COPD: acute exacerbations
Increasing dyspnoea
Increasing sputum volume
Increasing sputum purulence
(change in character)
→ treat as infective exacerbation

14. Initial management A-E - Sepsis! Oxygen –
high flow initally, consider controlled to aim sats 88-92% when stable
Nebulised bronchodilators
Steroids
Antibiotics (sepsis six pathway)

15. If not responding
Recheck A-E – your patient is probably septic and you haven't noticed
ABG
CXR
Consider NIV
Consider aminophylline

16. Case 2
An 76 year old man attends A+E with breathlessness. He has known COPD, with an FEV1/FVC 0.3, predicted FEV1 35% a few months ago. He uses oxygen at home, 2L for 16 hours a day. Over the last week he has had a productive cough with phlegm and fever.
His obs are RR 16, sats 85% on 2L oxygen, HR 110, BP 134/68, temp The examination shows crackles in his right lung base, but widespread wheeze throughout both lung fields.
The paramedics have given him a few salbutamol nebs and some IV hydrocortisone in the ambulance an hour ago but he is not improving as yet.
What's your initial management plan?

17. Case 2 continued
The nurse calls you as he has become drowsy. You take an ABG which shows pH 7.23, pO2 8.3kPa, pCO2 8.4kPa, HCO3- 24 mmol/l. His obs are repeated and show RR 12, sats 90% on 4L oxygen, HR 115, BP 115/68.
What is your management plan?
How would you start someone on NIV?
How would you monitor their progress on the ward?
What are the indications for NIV?
What are the contraindications?
List complications of NIV

18. NIV – non-invasive ventilation
Ventilation (V) = Tidal volume x Resp rate
Increase V, increase CO2 clearance

19. NIV – BiPAP diagram

20. NIV – indications in COPD
Respiratory acidosis (pH <7.35, PaCO2 >6kPa) – Hypercapnic respiratory failure
Persistent despite maximal medical therapy for no more than one hour

21. Other indications for NIV
Might be considered in:- controversial
Hypercapnic resp failure due to other causes
Cardiogenic pulmonary oedema
Weaning from tracheal intubation

22. NIV contraindications
- respiratory arrest
- uncooperative patients – confused
- unable to protect airway
- reduced conscious
- facial, oesophageal, gastric surgery
- face trauma

23. Starting NIV Dedicated area that allows high dependency nursing
HDU/ITU
Respiratory ward
A+E resus
Medical admissions
Not usually on a general ward – the nursing staff will not know how to deal with it

24. Starting NIV Physio or nursing help
Select settings for IPAP, EPAP and resp rate
IPAP start at 10cm H20
EPAP start at 5 cm H20
Backup rate of 8 breaths per minute
Most patients tolerate these settings, but may vary, especially those on long term NIV

25. NIV Management
IPAP increased by 2-5 cm H20 every 10 mins until either therapeutic response or IPAP of 20 cm H20 reached
Oxygen through circuit, aim sats 88-92%
Bronchodilators can continually be given though it affects the pressures

26. Monitoring NIV Baseline ABG, RR, HR
Repeat ABG after one hour of starting
After every setting change, repeat ABG at 1 hour
Otherwise, every 4 hours, or if not well
Aim minimum 6 hours treatment
Most people better by 24 hours on NIV
Weaning thereafter

27. Complications of NIV Increased IPAP – pneumothorax
Decreased pre-load – may drop BP
Increased risk of aspiration
Face mask discomfort
Anxiety + confusion

28. Escalation of care Plan for the failure of NIV
Are they appropriate for invasive ventilation and why?
Factors limiting survival
Pre-morbid state
Severity of physiological disturbance
Reversibility of acute illness
Relative contraindications
Patients wishes
Long term oxygen therapy

29. Decision making Consultant led, but involves MDT input
You as the FY1 can influence this
Nursing staff have valuable input
Involve the patient where possible
Family involvement is best practice
However we are not asking them to make a decision
Decisions are the responsibility of doctors

30. Palliation Symptoms of breathlessness are distressing
NIV can be continued if it provides symptom relief, but would normally be withdrawn
Opiates and benzodiazepines for breathless are optimal therapy
Palliative care team involvement
Liverpool care pathways

31. COPD Key Messages
Hypercapnic respiratory failure is indication for non-invasive ventilation in COPD
Call for early support (within 1 hour) of maximum medical therapy
Limits of care should be clearly planned when starting NIV

32. “Everything you wanted to know about kidneys but were afraid to ask”
AKI Questions
“Everything you wanted to know about kidneys but were afraid to ask”
Write down your question
Pass it forward
Answers later

33. Acute Kidney Injury - Objectives
To recognise AKI
To differentiate between pre-renal, renal and post renal causes of AKI
To recognise and manage hypovolemia
To manage hyperkalemia and pulmonary odema
To know indications for emergency dialysis
How to call a nephrologist without getting shouted at

34. 11/21/2011
June 2009

35. Definition of AKI Rise in serum creatinine >50% from baseline Or
Urine output <0.5ml/kg/hr for 6 hours

36. SIMPLIFIED RIFLE OR AKIN DEFINITION Usually based on Creatinine rise Loss and End stage components of RIFLE now dropped
Creatinine criteria
Urine output criteria
High
sensitivity
≥ % rise in Cr
Urine output <0.5 ml/kg/hr for 6 hours
(=240 ml at 80 kg)
Risk or
AKIN 1
% rise in Cr
Urine output <0.5 ml/kg/hr for 12 hours
(= 480 ml at 80 kg)
Injury
or AKIN 2
Urine output <0.3 ml/kg/hr for 24 hours or anuria 12 hours
>200% rise in Cr
High
specificity
Failure
or AKIN 3
Oliguria
11/21/2011

37. Which scenario is AKI? T/F/Can't tell?
85 male, D+V, creat 120, usually 80
2. 82 female, D+V, Urea 15.2, Creat 150
3. 60 male, diabetic, creat 250, usual 200
4. 74 male, legionella pneumonia, Na 118, Creat 130, usual creat 70
5. 63 female, diabetic, myocardial infarct, eGFR 25, usual eGFR 35
11/21/2011

38. Suspect AKI in a sick patient with a modest rise in their creatinine
Large acute drop in GFR with oligoanuria
GFR falls rapidly to near zero
- only shown by oliguria
Slow rise in Cr until
eventually a new steady state is reached
Only a small early rise in Cr: not easy to recognise as AKI
11/21/2011

39. Effect of AKI on odds of death Chertow GM et al J Am Soc Nephrol 2005
11/21/2011

40. Rise in serum creat > 50% baseline
baseline creatinine of 80 mmol/L
Rises to 120 mmol/L
Significant kidney injury
This is the moment to act – it is too late when the creatinine reaches 400
Mehta et al. Critical Care :R31

41. Case 3
66 year old man is admitted to A+E with breathlessness. He has been unwell for a week, coughing up phlegm and having fevers. His past medical history includes diabetes and hypertension. His medication is metformin, aspirin, ramipril, atenolol and simvastatin.
On examination he is unwell. His obs are BP 85/50, HR 115, Sats 92% on air, RR 25, Temp You hear coarse crackles on the right side of his chest. A CXR confirms pneumonia.
His blood results come back which show Na 130, K 4.5, Urea 14.3, Creat 189. The nurse asks you to assess him as he hasn't passed urine since admisssion.

42. Case 3 Outline the management you would undertake in A+E.
What is the likely cause for his renal failure?
Is this acute or chronic renal failure? How severe is his renal failure?
What investigations would you order and why?
What risk factors are evident in this man's case that make him more likely to have renal failure?
What information can be gained from a urine dipstick?

43. AKI risk factors Most people have > 1 risk factor Age
Drugs (ACEi, diuretics, NSAIDS)
Chronic kidney disease
Hypovolemia/Sepsis
Diabetes

44. AKI: causes
Important to attempt to categorise broadly into one of 3 groups
sepsis/hypovolemia 70%
drug related, acute GN 20%
obstruction 10%
PRE-RENAL
RENAL
POST-RENAL

45. Cause of AKI – 3 tests Fluid/volume assessment PRE Urinalysis RENAL
3 assessments result in a 45% 36 months survival, compared with 15% for 0 assessments
Fluid/volume assessment PRE
Urinalysis RENAL
Ultrasound POST

46. Question Which of these is the most useful indicator of hypovolaemia?:
capillary refill time > 5 seconds
jugular venous pulse not visible at 30º
postural pulse rise > 30 bpm
systolic blood pressure < 95 mm Hg
systolic BP rise with 250 ml saline bolus > 20 mm
11/21/2011

47. Volume assessment - key
MEWS score
Cap refill
BP, HR,
Postural BP
JVP
Auscultate lungs
Peripheral odema
Urine output

48. Volume assessment Is patient fluid depleted, euvolemic or overloaded?
You are the FY1 covering orthopedics. You have been asked to see 74 female post #NOF as she has low urine output
PMH - diabetes, hypertension
Creat 150, baseline 100, urine output 20mls in last hour
CRT 2 secs, BP 110/50, HR 98, JVP ??, chest couple of creps, no edema
Is patient fluid depleted, euvolemic or overloaded?
How much fluid would you prescribe?

49. Volume management Most patients are hypovolemic (70%)
If not grossly overloaded – fluid challenge
- 500ml + recheck
“Normal” BP for 75 year old – 150/70
- a post op BP of 110 is relatively hypotensive

50. Volume assessment
Most patients are likely 2-3 liters or more fluid deficient
Sepsis – doubly important

51. Urinalysis Ie glomerulonephritis
- this points towards intrinsic renal disease
Ie glomerulonephritis
- blood and proteinuria on dipstick = nephrology referral

52. AKI investigations u/s urinary tract
- suspect obstruction in men with prostatic symptoms
- palpable mass
- intra-abdominal malignancy compress ureters with no bladder palpable females
- where cause not obvious

53. AKI investigations - fluid assessment - urinalysis - u/s urinary tract
By doing all 3 investigations survival significantly improved
- fluid assessment
- urinalysis
- u/s urinary tract

54. AKI QUESTION TIME

55. Hyperkalaemia - True/False
1. Calcium gluconate acts by reducing the serum potassium T/F
2. Insulin/dextrose infusion requires 30mins to shift potassium into cells T/F
3. Insulin/dextrose infusion effects last for 24 hours T/F
4. Salbutamol nebulisers have the same effect as insulin/dextrose infusion T/F
5. IV sodium bicarbonate can reduce potassium T/F
6. to treat hyperkalemia you would prescribe 50 units of actrapid in 50ml 50% dextrose T/F
7. 10ml of 10% Calcium gluconate is the correct prescription for the treatment of hyperkalemia T/F
8. Calcium resonium acts within minutes to reduce serum K T/F

56. Hyperkalemia
K+ >6.5
- 1st – repeat measure on VBG/ABG (takes 5 mins)
- if true – ECG
- if life threatening changes
Calcium gluconate 10ml 10% stat (through big vein – tissue burns)
- thereafter 10 units actrapid in 50mls 50% glucose over 30 mins.
11/21/2011

57. Hyperkalemia Insulin/dextrose – lasts 4 hours only
- in meantime correct cause of high K
- Repeat ABG at 4 hours to see if better
If K+ still high – DIALYSIS MAY BE INDICATED
11/21/2011

58. Hyperkalemia - caution in cardiac disease
Salbutamol nebs (10-15mg) have same action as insulin/dextrose and may be an option
- caution in cardiac disease
IV sodium bicarbonate 1.26%
- useful in dehydrated patient who is ACIDOTIC
- discuss with senior, but consider if HCO3 <18 and needs ongoing fluid replacement
- worsens pulmonary oedema ++
11/21/2011

59. Hyperkalemia Key is to recheck after treatment
Correct underlying cause
Consider dialysis
11/21/2011

60. Pulmonary oedema in AKI
ABCDE approach
Oxygen
GTN infusion
Diamorphine
Consider large dose furosemide 250mg IV
CPAP
ITU/ventilation
Correct cause of renal failure (days)
11/21/2011

61. Dialysis indications Resistant hyperkalaemia >6.0
Consider haemodialysis/haemofiltration if:
Resistant hyperkalaemia >6.0
Fluid overload and no urine output
Persistent acidosis pH<7.2
Call for senior support in all cases
Nephrology referral for dialysis patients admitted under any other specialty

62. When to call nephrology
Any known dialysis patient admitted
Any known renal transplant patient admitted
Any case of AKI where cause not clear
Worsening AKI
Emergency dialysis indications
Suspect glomerulonephritis

63. What info to have when calling nephrologist
Your (boss') reason for referral
The history and background in your head – dont read the notes to me – check with patient if not clear history
The notes by the phone
The obs chart by the phone (MEWS, Urine output)
A urine dipstick result
Your assessment of the patients fluid status
An up to date venous blood gas (that day)

64. AKI: Summary
Small changes in creatinine can have grave clinical consequences
ABCDE assessment and careful management of fluid status is mainstay of treatment
Get help early

65. What abnormalities can be seen?

66. ECG features of hyperkalaemia
Any of:
Small or absent p waves
Arrhythmia-commonly AF
Wide QRS complexes
Increased P-R interval
Peaked, tented T waves
Sine wave pattern
Asystole!

67. Pulmonary Oedema T/F
1. Pulmonary oedema in a patient with pre-renal failure will respond to a fluid challenge T/F
2. Furosemide 40mg IV will likely produce symptom relief T/F
3. GTN infusion works in renal failure to relieve breathlessness T/F
4. Venesection can be used to treat pulmonary oedema if the BP is <100mmHG T/F
5. Patients in pulmonary oedema who are oligo/anuric will likely require dialysis T/F
11/21/2011

68. 11/21/2011

69. Question 1 % creatinine rise % estimated GFR fall
For most patients with AKI what is the most useful means of classifying the presence and severity of AKI:
% creatinine rise
% estimated GFR fall
creatinine rise in micromoles/litre
estimated GFR in ml/min/1.73m2
urine volume in ml/kg/hour
11/21/2011

70. Question 2 acute interstitial nephritis acute tubular necrosis
What is the main diagnosis you are looking for when you do a dipstick in a new case of AKI?
acute interstitial nephritis
acute tubular necrosis
obstructive uropathy
glomerulonephritis
renovascular disease
11/21/2011