Assessment of clubbing

A number of conditions associated with clubbing require urgent evaluation and treatment.

Pulmonary

Lung cancer

• Emergency care may be necessary depending on the presentation.

• If the patient has upper airway obstruction, urgent admission to the intensive care unit (ICU) is required. Fibre-optic laryngoscopy or intra-operative tracheostomy may be necessary to help relieve the obstruction.

• Sometimes patients present with severe haemoptysis. In such cases, immediate suctioning is indicated. If respiratory failure is imminent, an endotracheal tube should be placed. The patient will require an urgent blood transfusion, and a pulmonologist may have to perform fibre-optic bronchoscopy. All patients, except those with the most minor bleed, need intensive care.

Empyema

• Respiratory failure can occur, requiring assisted ventilation in an ICU. Intubation may be necessary. If pulse oximetry shows low saturation, supplemental oxygen should be started immediately.

Pulmonary metastases

• The extent and position of metastases are important considerations. Metastases impinging on major airways or eroding into major intrathoracic vessels can result in massive haemoptysis and shock. This risk, and possible management options, should be discussed with the patient. These patients may require emergency management in an intensive care ward. Establishment of venous access, transfusion of blood products, management of shock with fluids, and cardiosupportive measures are usually the initial steps.

• A thoracic surgery team should be on standby for an emergency thoracotomy if indicated. For some patients, a plan to palliate symptoms in the event of massive haemoptysis caused by metastases is appropriate.

Pulmonary tuberculosis

• This is infectious and requires administration of antituberculous drugs immediately. The patient may require respiratory isolation if there is open discharge of bacilli.

• Notification to appropriate healthcare agencies is mandatory.

Pleural mesothelioma

• Patients can present with a pleural effusion. All patients with rapidly collecting effusions need evaluation in the emergency department. Urgent placement of an intercostal drain may be required.

Lipoid pneumonia

• Hypoxia and respiratory distress, although rare, can occur in severe cases. Urgent ventilatory support is required.

Pulmonary artery sarcoma

• Patients may present to the emergency department with a massive bleed, shock, and collapse. Haemoptysis is a warning sign. Thoracotomy and intervention by a pulmonary care intensivist and thoracic surgeon will be required.

Cardiovascular

Right-to-left shunting

• Infants with cyanotic congenital heart disease (e.g., tetralogy of Fallot, double outlet right ventricle, transposition of great vessels) or other causes of right-to-left shunting (e.g., patent ductus arteriosus and coarctation of the aorta) may present with symptoms and signs of congestive heart failure. Consult a paediatric cardiologist urgently.

• Pharmacological therapy should be given promptly before surgical interventions are considered.

Infective endocarditis

• Patients may present to the emergency department with congestive heart failure or even renal failure requiring urgent therapy and possibly dialysis.

Atrial myxoma

• This can occasionally cause a stroke due to embolisation. In such cases, urgent medical attention is required, as a successful outcome depends on rapid evaluation, diagnosis, and intervention.

Axillary artery aneurysm

• This can sometimes result in a pulmonary embolism. Fibrinolysis, heparin, oxygen, and intravenous fluids may be required. In severe cases, emergency bypass is necessary.

Brachial arteriovenous malformations

• This may result in embolisation, pain, or distal gangrene. Urgent admission, delineation of the aneurysm and possible resection, or resolution of embolic episodes are required.

Hepatobiliary

Cirrhosis

• May result in the alteration of clotting parameters or varices causing an acute bleed, requiring urgent sclerotherapy, transfusion, and endoscopic assistance. Deterioration of metabolic status can lead to coma and hepatorenal failure, requiring intensive care.

Gastrointestinal

Ulcerative colitis

• Ulcers can occasionally cause severe haematochezia and rectal bleeding. These patients need an emergency colonoscopy and sometimes resection of the affected bowel segment.

Crohn's disease

• Intestinal obstruction can develop due to bowel wall thickening by acute inflammation. Presents with abdominal pain, nausea, vomiting, abdominal distension, and dilated bowel loops and air-fluid levels on x-ray.

• Treatment involves bowel rest with nasogastric suctioning and may require corticosteroid therapy. Patients not responding to these measures require surgical resection.

Ulcerative oesophagitis

• Patients can present with vomiting and haematemesis if the ulcer erodes into the wall of the oesophagus. Emergency assistance is required, with oesophagoscopy to arrest bleeding and possible transfusion of blood products.

Non-pulmonary malignant

Disseminated chronic myeloid leukaemia

• Advanced cases can occasionally alter the coagulation cascade and produce disseminated intravascular coagulation. This requires urgent replacement with plasma and anticoagulant therapy immediately after evaluation.

Other

Secondary hypertrophic osteoarthropathy

• May be due to a sinister underlying cause (including adenocarcinoma of the lung, as well as other malignancies including metastatic disease); thus, its presence should alert the physician to the need for a thorough and urgent investigation.