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Senior - EMED 2 > 7 - Pneumothorax > Flashcards

7 - Pneumothorax Flashcards

1
Q

What is a pneumothorax?

A

Free air entering the potential space between the visceral and parietal pleura

Not potential space anymore

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2
Q

Primary v secondary pneumothorax?

A

Primary: no lung disease

  • spontaneous
  • 2/2 trauma

Secondary: underlying lung disease

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3
Q

What keeps the lungs “inflated”?

A

The parietal and visceral pleura are in close apposition

Pleural space is neg pressured at -5mmHg (fluctuates w inspiration/expiration)

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4
Q

What occurs when a primary pneumothorax erupts?

A

Primary spontaneous pneumothorax occurs when a subpleural blep ruptures, disrupting pleural integrity

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5
Q

Primary pneumothoraces usually occur?

A

At the lung apex

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6
Q

What happens with a secondary spontaneous pneumothoraces?

A

Disruption of the visceral pleura occurs 2/2 the underlying pulmonary disease processes

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7
Q

Simple explination for pneumothorax?

A

The lung ruptures
Air follows the path of least resistance, so rather than go out the mouth hole it goes out the new lung hole into the potential space
This creates a disruption in the pleural space creating a positive pressure
Now the lung starts to collapse

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8
Q

When does a tensionpneumothorax develop?

A

Inhaled air accumulates in the pleural space but cannot exit due to a check-valve system

Once pressure is >15mmHg the heart and vessels shift contralaterally

This affects venous return, diastolic filling and CO

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9
Q

The crushing pressure on the great vessels and heart leads to a?

A

Ventilation-perfusion mismatch —> hypoxia and shock

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10
Q

Tension pneumo with a chest tube?

A

Yeah if you dont do it right and gas egress is obstructed

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11
Q

Classic symptoms of primary spontaneous pneumo?

A 
Sudden onset of:
- dypsnea
- chest pain that is 
—-ipsilateral
—-pleuritic

Profound dypsnea is rare unless they are already sick

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12
Q

How long does the pleuritic component of the pneumothorax take to resolve?

A

24hrs

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13
Q

MC physical finding with spontaneous pneumo?

A

Sinus tachycardia

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14
Q

If pneumothoraces are small classic findings may not present, these findings are?

A
  • ipsilateral decreased breath sounds
  • hyper-resonance to percussion
  • decreased/absent tactile fremitus
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15
Q

With traumatic pneumo ___ has a positive predictive value of 86-97%?

A

Ipsilateral decreased breath sounds

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16
Q

Clinical hallmarks of tension pneumo?

A

Tracheal deviation (contralateral)
Hyperresonance
HOTN
Sig dypsnea

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17
Q

Symptoms that are not commonly found?

A

Cough

Exertional complaints

18
Q

Consider pneumothorax with pts who have chest pain but it also could be?

A

Pleurisy
Pleural effusions
Infiltrates
Shingles

Look like pneumothorax

19
Q

This bedside test is super sensitive and specific for pneumo?

A

US

20
Q

US will show?

A

Seashore:

Movement of lung (ocean) against the stationary chest wall (shore)

21
Q

What does normal lung look like on US?

A

Normal lung sonographic reverberation distal to the pleura that looks like a comet tail and sliding sign of movement of visceral pleura along parietal pleura

Basically a wedge of lung and 2 rib shadows

22
Q

What US mode do you use?

A

M mode
- motion mode

14-19 have pics

23
Q

CXR kinda sucks for pneumo but ___ is pretty great

A

CT

  • not only can it see more pneumos
  • it can show pulmonary blebs

21-25 has pics

24
Q

ED treatment goal?

A

Eliminate intrapleural air

25
Q

You suspect tension pneumothorax, now what?

A

Dont wait on radiology

  • needle D
  • tube thracostomy
26
Q

what is SWAG? Give me an example

A

SWAG - scientific wild ass guess

Example: w/o supplemental o2 a 25% pneumo would take approx 20 days to resolve

27
Q

Who gets to go home?

A

You can do observation for small, stable pneumothoraces
- observe x 4hrs on o2 then repeat CXR

If still good have them return in 24hrs
- Return to the ED not PCM

28
Q

What is the decision to use aspiration or a tube thoracostomy based on?

A

Likelihood of recurrence and likelihood of spontaneous resolution

29
Q

Who tends to need a chest tube?

A

Likely to recur and need a chest tube:

  • Underlying pulm disease
  • Large pneumo
  • Inability to return to hospital
  • Unable to tolerate pneumothorax (poor cardiac reserve)
30
Q

Complications of pneumo?

A

Those due to

  • hypoxia
  • Hypercapnia
  • HOTN
Reexpansion injury
Intercostal hemorrhage
Lung parenchymal inj
Empyema
Tube malfunction (air leak)
31
Q

When are reexpansion lung injurys likely to happen?

A

They are unlikely but seen w:

  • collapse of >72hrs
  • large pneumothorax
  • rapid reexpansion
  • negative pleural pressure suction >20cm
32
Q

Tx for reexpansion injury?

A

Observation
Oxygen

“These guys do great”

33
Q

What is pleurodesis?

A

Used for recurrence prevention on:

  • 1st spontaneous pneumo
  • 2nd ipsilateral spontaneous
  • 1st contralateral pneumo
  • bilateral spontaneous pneumo
  • 1st episode of 2ndary pneumo
  • recurrent high-risk activities (skydiving, scubadiving)
34
Q

What is iatrogenic pneumo?

A

Subset of traumatic pneumo
- more common than spontaneous

Iatrogenic - hospital induced

35
Q

What causes iatrogenic pneumos?

A

Transthoracic needle procedures (needle biopsy, thoracentesis)

Subclavian vein catheterization

This is often under-detected and underreported, honestly we don’t do these procedures on healthy patients, we may not even notice we punctured the guys lung who had 6 GSWs to the chest

36
Q

Techniques to reduce iatrogenic pneumos or at least find them early?

A

US guidance for central lines and thoracentesis

CXR is routine but often misses the pneumo so not useful

37
Q

Tx for iatragenic pneumo?

A

The same as spontaneous
Its just a small pneumo (hopefully)

Prob do a simple catheter aspiration

38
Q

Concern for pneumothoracies, particularly for military applications?

A

Boyle’s law - tensions are more likely when you are transported in aircraft

We may have trouble evacuating these people out of theater

39
Q

High-altitude flying is not recommended for:

A

7-14 days after resolution

40
Q

“Youll never catch me…”

A

Scubadiving - same thing pressure changes and stuff

  • no scuba w hx of pneumos
  • unless treated w surgical pleurectomy

Senior - EMED 2 (10 decks)

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