L16 - Surgery Trauma / Pneumothorax / Foreign Body / Cancer / Transplant Flashcards

1
Q

What is a flail chest?

A

Movement of segment of chest wall.

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2
Q

Causes of flail chest?

A

Significant force diffused over large area of thorax.

If patient has osteoporosis: less force required

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3
Q

Describe muscles in chest

A

Intercostal muscles with fascial attachments.
Includes
- trapezius
- serratus

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4
Q

Describe diagnostic methods to detect a flail chest

2 methods and what do they show

A

CXR

  • demonstrate fractured ribs
  • hypovolemia may initially mask underlying pulmonary contusion

ABG
- will show severity of hypoventilation created by pulmonary contusion and pain of rib fractures

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5
Q

Treatment options for a flail chest

A
  • Patient controlled analgesia
  • Oral pain medication
  • Indwelling epidural catheter
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6
Q

Haemothroax

A

Collection of blood within pleural cavity.

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7
Q

Haemothorax may be a consequence of…

A

Blunt, penetrating trauma.

Complication of disease.

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8
Q

Describe extrapleural injury which may cause haemothorax

A

Extrapleural Injury

- trauma to chest wall tissues with violation of pleural membrane

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9
Q

Sources of significant persistent bleeding which may cause haemothorax

A

Intercostal and internal mammary arteries.

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10
Q

Describe intrapleural injury which may cause haemothorax

A

Intrapleural injury

- blunt, penetrating injury involving any intrathoracic structure

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11
Q

Describe major arterial, venous structures within the thorax that may be involved in intrapleural injury

A
Aorta 
Brachiocephalic branches 
Pulmonary arteries 
SVC 
Brachiocephalic vein 
IVC 
Azygous vein
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12
Q

Haemodynamic response to haemothorax

A

Heavy blood loss may cause early symptoms of shock:

  • tachycardia
  • tachypnea
  • decrease in pulse pressure
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13
Q

Describe physiologic resolution of haemothorax

A
  • Blood entering pleural cavity exposed to motion of diaphragm, lungs and other intra-thoracic structures
  • results in some degree of defibrination of blood
  • incomplete clotting occurs
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14
Q

How might small, asymptomatic haemothorax progress into large and symptomatic bloody pleural effusion

A
  • Lysis of existing clot by pleural enzymes
  • increase in protein concentration in pleural fluid
  • results in increase in osmotic pressure within pleural cavity
  • Transudation of fluid into pleural space
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15
Q

Later stages of haemothorax may lead to…

A

Empyema

Fibrothorax

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16
Q

Empyema

A
  • Bacterial contamination of retained haemothorax

- may lead to bacteremia, or septic shock if left untreated

17
Q

Fibrothorax

A
  • Fibrin deposition develops in an organised haemothorax.
  • Coats both parietal and visceral pleural surfaces.
  • Adhesive process traps the lung in position
  • Prevents lung expansion
18
Q

Pneumothorax

A

Abnormal collection of air in pleural cavity between lung and chest wall

19
Q

Primary spontaneous pnuemothorax

A

Occurs without an apparent cause in absence of significant lung disease

20
Q

Secondary spontaneous pnuemothorax

A

Occurs in the presence of existing lung disease

21
Q

Typical symptoms of pneumothorax

A
  • Sudden onset sharp, one sided chest pain.

- Shortness of breath

22
Q

Describe how a tension pneumothorax occurs?

A
  • There’s an area of damaged tissue.
  • One way valve formed.
  • Amount of air in chest increases.
  • Results in tension pneumothorax.
23
Q

Differential diagnosis for pneumothorax

A

lung bullae

haemothorax

24
Q

Diagnostic method for pneumothorax

A

CXR, USS, CT

25
Q

Tactile fremitus

A

Fremitus: vibration transmitted through body

26
Q

What may increased tactile fremitus show?

A

Ask patient to repeat ‘99’ while examiner feels vibrations.

Tactile fremitus increased over areas of consolidation

27
Q

What may decreased tactile fremitus show?

A

Decreased in area of pleural effusion / pneumothorax

28
Q

Describe how haemothorax may develop into large bloody pleural effusion?

A
  • blood entering plueral cavity exposed to motion of diaphragm etc.
  • some degree of defibrination of blood
  • incomplete clotting occurs
  • after cessation of bleeding, lysis of osmotic clots by pleural enzymes
  • RBC lysis leads to increased protein concentration of pleural fluid
  • causes transduction of fluid into pleural space.
  • hence small and asymptomatic haemothroax may progress into large pleural effusion
29
Q

Describe dangers of tension pneumothorax

A
  • Pressure build up in pleural space, compressing lung.
  • Mediastinal shift to opposite side.
  • Progressive kinking IVC.
  • VC eventual obstruction.
  • MEDICAL EMERGENCY*
30
Q

Tension pneumothorax

A
  • injured tissue forms one way valve
  • volume of nonabsorpable intrapleural air increases
  • pressure arises within affected hemithorax
  • pressure increases
  • ipsilateral lung collapses and causes hypoxia
31
Q

Cardiac tamponade

results in:

A
  • accumulation of fluid in pericardial fluid
  • reduced ventricular filling
  • subsequent haemodynamic compromise
32
Q

Management of cardiac tamponade

A

Emergency subxiphoid percutaneous drainage.

- movement of pericardial fluid

33
Q

3 Phases of haemodynamic changes in tamponade

A
  1. Accumulation of pericardial fluid, impairs relaxation and filling of ventricles.
  2. Pericardial pressure increases above ventricular filling pressure.
  3. Decreases in cardiac output.
34
Q

Beck’s triad

A
  • Increased JVP
  • hypotension
  • diminished heart sound
35
Q

Pulsus paradox

A

Normal inspiratory decrease in systemic BP.

While listening to heart sounds during inspiration, pulse weakens or may not be palpated with certain heart beats.

36
Q

Subcutaneous emphysema

A

When gas or air travels under skin

37
Q

Pathophysiology of subcutaneous emphysema

A
  • injury to parietal pleura that allows for passage of air into pleural space and subcutaneous tissues.
  • air from alveolus spreading into endovascular sheath.
38
Q

Pulmonary contusion

A

Blunt injury to lungs causing oedema.

Hypoxia.

Treatment supportive
- humidified o2, pain relief, ventilation