Chest trauma, Second Lecture, Tracheal stenosis, Cancer Flashcards
CDEE’s diagnosis
- Chest tube
- has to be >8.4mm
- 5-6 ICS, mid axillary line - Diagnostic studies - bronchoscopy, endoscopy, transesophageal echocardiography
- Endoscopy
- Emergency thoracotomy
- F - fly to center
Indications for emergency thoracotomy (8)
- tamponade of the heart
- worsening hemodynamics
- main vessels injury
- esophageal injury
- foreign bodies in main vessels
- chest wall defect
- massive air leak
- injury of the mediastinum
Injury of the heart: Claude Beck’s triad
- hypotension
- weak heart tones
- enlargement of neck veins
Injuries of blunt chest trauma can be…
High energy
Low energy - pneumothorax, subcutaneous emphysema, hemothorax
Flail chest
- fracture of the ribs in 2 or more places, 3 or more ribs are injured
- usually in car accidents
- pulmonary contusion
Flail chest
-treatment
- treatment: intubation –> mechanical vent. till ribs are healed –> surgery
- stabilization of the chest wall with orthopedic intramedullary nail
Pneumothorax
-classification
- Spontaneous - primary, secondary, recurrent
- Traumatic - open or closed
- Tension –> life-threatening, pressure progressively increases
Pneumothorax
-symptoms
- sudden, severe, stabbing ipsilateral (same side) chest pain
- sudden onset dyspnea
- in tension pneumothorax –> acute respiratory distress syndrome, tracheal deviation, hemodynamic instability
Pneumothorax
-diagnosis
- chest x-ray –> decreased or absent lung marks, deep costophrenic angle (ipsilaterally), hemidiaphragm elevation
- if tension pneumothorax is suspected –> immediate chest tube placement, no imaging
Open vs. closed pneumothorax
Closed - air enters through a hole in the lung
- ex: following blunt trauma
- treatment: chest tube
Open - air enters through a lesion in the chest wall
- ex: following penetrating trauma
- treatment: partially occlusive dressing and then a chest tube
Tension pneumothorax
- air enters –> cannot exit –> compresses organs, lungs collapse –> impaired resp. function –> decrease venous return –> decrease cardiac output = hypoxia
- chest x-ray - diaphragmatic flattening or inversion, mediastinal shift, tracheal deviation
Subcutaneous emphysema
- definition
- origin (4)
- treatment
- air goes into the chest wall tissues - “air is trapped under the skin”
- origin: from outside, pneumothorax, mediastinal emphysema, pleural tear
- collar mediastinotomy
Causes of mediastinal emphysema (7)
- subcutaneous emphysema
- pneumothorax with mediastinum pleura tear
- barotrauma
- bronchial rupture
- esophageal rupture
- tracheal rupture
- pulmonary laceration
Hemothorax
- indication for thoracotomy (3)
- sources of bleeding (6)
- > 300ml/hour for >2h or >1.500ml
- injury of the heart
- mediastinal hemorrhage with compression of major veins or major airway
- intercostal or internal mammary artery
- supra-aortic vessel rupture
- diaphragm rupture
- pulmonary laceration
- pericardial or cardiac rupture
- isthmic rupture of the aorta
Traumatic rupture of the aorta
-phases
- first phase - haemomediastinum - aortic adventitia and mediastinal pleura are intact
- free interval - pseudo-aneurysm - organization of hematoma
- second phase - secondary rupture of the mediastinum (blood into the pleural cavity)
Lung carcinoma
-screening (6)
- sputum cytology - effective in small tumors
- chest x-ray
- bronchoscopy
- Telomerase activity, DNA anomalies, genetic mutations
- CT, PET
- early diagnostics - low dose spiral CT, blood serum mikroRNR
Lung cancer
-mediastinoscopy - indications and results
- indications: enlargement of mediastinal lymph nodes and staging of lung cancer
- if negative –> surgery
- if positive –> chemo, then surgery
Lung cancer
-surgical management of NSCLC
-the gold standard - lobectomy - with regional or systemic lymphadenectomy
Lung cancer
-stereotactic body radiation therapy (SBRT)
- usually done in older patients, mainly T1 cases
- results are not that good because it ignored lymph nodes and satellite nodes, histology is not always proven
Lung cancer
-main complications after pulmonary resection (6)
- prolonged air leak
- postop pneumonia
- bronchopleural fistula
- PATE
- hemothorax
- suppuration
Prolonged air leak after pulmonary resection
- > 7 days
- main reason: lung tissue insufficiency
- how to avoid –> good suturing, stabling devices, avoid ventilation with positive PEEP
Post-intubation tracheal stenosis
- etiology (3)
- etiopathogenesis
-pressure necrosis at tube level, tracheostomy procedures errors, error in tube management
- at 20mmHg - superficial, non-progressive, after 15min damage
- at 50 mmHg - partial damage of basement membrane, after 15min
- at 100 mmHg - damage down to the cartilage + bacterial invasion
Post-intubation tracheal stenosis
-diagnostics (3)
- tracheal tomogram
- bronchoscopy
- chest CT
Post-intubation tracheal stenosis
- emergency management
- main reasons for inoperability
-rigid bronchoscopy under general
- laryngeal involvement
- limited residual length of normal trachea
- unsatisfied general conditions of the patient
T tube stenting of the airway
- who came up with it
- indications (4)
- Montgomery
- temporary stenting of the airway, definite procedure for palliation of airway obstruction, unresectable malignancy, complications of airway reconstruction
Lung cancer
-clinical features of other systems (4)
- pancoast syndrome
- hydrothorax and hydropericardium
- superior vena cava syndrome
- dysphagia
