Cardiothoracics Flashcards
what is a pneumothorax
presence of air in the pleural pace —- w varying degree of secondary lung collapse
what are the types of pneumothorax?
spontaneous pneumothorax
primary: no obv reason or apparent lung disease
secondary: due to known underlying lung or systemic disease
traumatic pneumothorax
what is the typical presentation of primary spontaneous pneumothorax
tall young male
right lung apex
in the middle of exercise
management of spontaneous pneumothorax
conservative Tx = supplemental O2 + repeat CXR
indication: small (<20%) + asymptomatic
needle aspiration
Location: 2nd intercostal space midclavicular line
indication: >2cm rim of air
chest tube insertion
indication: failure of needle aspiration
surgical Tx = VATS video assisted thoracoscopic surgery
what is a tension pneumothorax and what causes it?
It is when pneumothorax associated with high pressure within the pleural space, decreasing venous return and compressing bilateral lungs.
it is due to a one-way valve either through the lung or the chest wall, such that air is forced into the pleural space and cannot escape. This generates pressure so high that the ipsilateral lung collapses completely and mediastinum shifts to the opposite side, decreasing venous return and compressing the contralateral lung.
how would tension pneumothorax present?
symptoms (Hx)
chest pain
shortness of breath
dizziness
agitation
signs (exam)
abnormal vitals — tachypnoea, tachycardia, hypotension
tracheal deviation away from affected side
unilateral absence of breath sounds
hyperresonance to percussion
neck V distension
+/- subcutaneous emphysema
what Ix can be done for tension pneumothorax
Hx & Physical exam
eFAST extended focused assessment w sonography in trauma — absence of lung sliding!!
how would u manage a tension pneumothorax?
ABCDs
supplementary O2 if needed
2 parts — initial needle decompression then insertion of definitive chest drain
needle decompression
location: 2nd intercostal space mid-clavicular line (ie ICS felt nearest to the clavicle since the 1st ICS is behind the clavicle)
chest drain insertion
location: triangle of safety or 4th/5th ICS anterior to mid-axillary line
anterior: pec major
posterior: latissimus dorsi
inferior: horizontal line superior to nipple
superior: horizontal line inferior to axilla
if just air = direct drain to lungs or upwards vs if haemothorax = direct down or if both = 2 drains needed!
connect drain to underwater seal + put drain on ground lower than lungs
complications of chest drain insertion for pneumothorax
early
haemothorax — tube inserted into lung or pierced through A
lung laceration
diaphragm & abdo cavity penetration
bowel injury if had diaphragmatic hernia
tube placed incorrectly — subcutaneously or too far or displaced
late
blocked drain (eg. clot)
retained haemothorax
empyema
pneumothorax after drain removal
indications for CABG
> 70% left main stem stenosis
symptomatic + >70% proximal LAD stenosis
symptomatic + >70% disease in all 3 vessels
concomitant valvular disease requiring replacement
vessel disease (as above) in DM patient
what grafts can be used in CABG?
venous graft: long saphenous V (most common)
arterial graft:
left internal mammary A
left internal thoracic A
radial A
difference between mechanical valve & bio-prosthesis
lifetime
mechanical = life-long — >20 yrs
bio-prosthesis = shorter — 10-15 yrs
warfarin
mechanical = requires
bio-prosthesis = doesnt require
on physical exam
mechanical = noisy (metallic click)
bio-prosthesis = silent
