Mehlman trauma/pleural 03-11 (3) Flashcards
Pulmonary contusion. how to establish diagnosis on USMLE?
Difficult diagnosis.
Diagnosis of exclusion.
Pulmonary contusion.
Q: accident + now has some form of difficulty breathing and patchy infiltrates in one or more areas of lung. They may or may not mention rib fractures just above the areas of infiltrates.
.
Pulmonary contusion.
textbook description (apie xray)?
“white-out of the lung”
Pulmonary contusion. sensitive to what?
Contused (bruised) lung is known to be fluid-sensitive.
Pulmonary contusion.
Q can say patient was given IV saline and now has worsening of O2 sats -> Dx?
Pulmonary contusion.
This is classic, but I’ve also seen this in myocardial contusion questions, making the Dx difficult as I said.
But you’ll be able to eliminate myocardial contusion if they don’t mention severe bruising or pain over the sternum or post-MVA arrhythmia (e.g.,
premature atrial contractions).
patient has paradoxical breathing (i.e., the chest wall moves outward with expiration and inward with inspiration). Dx?
Flail chest
Flail chest, definition?
patient has paradoxical breathing (i.e., the chest wall moves outward with expiration and inward with inspiration).
Ruptured bronchus, definition?
The answer on 2CK forms if they say there’s a “persistent air leak despite
placement of a chest tube.” This will be in a trauma patient.
“persistent air leak despite
placement of a chest tube.” This will be in a trauma patient.
Ruptured bronchus
Diaphragmatic rupture. definition?
The answer on 2CK forms for an MVA followed by CXR showing “obscured left
hemidiaphragm and the NG tube present in the lower left side of the chest.”
MVA followed by CXR showing “obscured left hemidiaphragm and the NG tube present in the lower left side of the chest.” Dx?
Diaphragmatic rupture
Dont confuse with what two pathologies that also can occur after trauma?
Don’t confuse with ruptured bronchus above, or with esophageal rupture, which
will tell you water-soluble contrast swallow is visualized in the mediastinum
Pleural effusion. definition?
Fluid in the pleural space; often refers to “hydrothorax,” which means transudate or exudate of plasma-like fluid.
Pleural effusion. USMLE wants what CP findings?
dullness to percussion,
decr. breath sounds,
decr. tactile fremitus.
both decr. because fluid in the overlying pleural space masks air movement in the alveoli.
Pleural effusion. many causes on usmle.
what notable?
I’ve observed left heart failure as a notable cause (i.e., patient will have pulmonary edema +/- pleural effusion).
NBME can also give you pleural effusion with pneumonias, tuberculosis, and aortic dissection.
Pleural effusion. Meigs syndrome, what is it?
triad of ovarian fibroma, ascites, right-sided pleural effusion.
Pleural effusion.
triad of ovarian fibroma, ascites, right-sided pleural effusion.?
Meigs syndrome
Pleural effusion.
USMLE wants you to know transudative versus exudative pleural effusions. how they look like?
transudates are more water-like, with fewer solutes; exudates contain more
solutes.
Pleural effusion.
Light criteria (HY!!!), exudate:
Pleural fluid protein : serum protein ratio?
Pleural fluid protein : serum protein ratio >0.5.
Pleural effusion.
Light criteria (HY!!!), exudate:
Pleural fluid LDH : serum LDH ratio?
Pleural fluid LDH : serum LDH ratio > 0.6.
Pleural effusion.
Light criteria (HY!!!), exudate.
In other words, transudate contains less protein and LDH as the two main distinctions
.
Pleural effusion.
Light criteria (HY!!!), exudate:
Pleural fluid LDH ……… of normal of serum LDH.
Pleural fluid LDH >2/3 upper limit of normal of serum LDH.
Pleural effusion.
Transudates contain fewer WBCs than exudates, but I routinely see 500 WBCs/µL in transudate Q on NBME.
.
Pleural effusion.
Highest yield cause of transudate on USMLE?
left heart failure
Pleural effusion.
HY cause exudative pleural effusions (due to inflammation)?
ARDS, pulmonary emboli, and infections
Pleural effusion. progress to what?
Progression to empyema HY (see below).
Empyema. 2 ways on usmle.
.
Empyema.
4/5 Q. Will be sequence: pneumonia -> parapneumonic effusions (exudative effusions that occur due to pneumonia) -> empyema.
pH of empyema? HY
<7,1
Empyema.
1/5 Q. will not mention Hx of pneumonia.
Case: patient with persistent fever + recurrent pleural effusions due to cirrhosis (decr. oncotic p. -> transudative pleural effusions). Dx?
Empyema.
Empyema. Tx?
nbme wants THORACOSTOMY to drain the purulence.
Chylothorax. definition?
Chyle (lymph fluid) in pleural space.
Chylothorax.
Q. Milky/white-cloudy fluid in the pleural space WHERE pH is significantly higher than 7,1.
.
Chylothorax. pH?
significantly higher than 7,1.
Chylothorax.
they might give you 15-line paragraph where they say milky fluid + tons of lab values, but you notice the pH of the pleural fluid is 7.40. This means it’s chylothorax and empyema is wrong.
.
Chylothorax. causes?
Can be caused iatrogenically by insertion of central line via the left internal jugular vein, or by cancers, e.g., lymphoma
Hemothorax. definition?
Blood in the pleural space.
Hemothorax. apart from massive trauma, what in other case in usmle can occur?
The way this shows up on USMLE is as malignant pleural effusion
Hemothorax.
They’ll give you massive paragraph with tons of info + tell you patient has history of breast or lung cancer + has dullness to percussion = answer?
malignant pleural effusion
Hemothorax. CP simmilar to what?
Patient can have hypotension and muffled heart sounds, similar to cardiac tamponade, but rather than JVD (to complete Beck triad), can have flattened neck veins (due to loss blood from the circulation).
