Path 2.0 Flashcards
What are the classifications of Chest Trauma?
50% - Chest wall injuries
26% - Pulmonary injuries
20% - Cardiovascular injuries
4% - Other (esophageal/diaphragmatic injuries)
What is the initial management of Chest Traumas?
1.Airway stabilization (c-spine control!!)
2.Breathing and ventilation
3.Circulation with hemorrhage control
4. Disability/neurologic status
Exposure
” ABCD”
What are examples of Chest Wall injuries?
Soft tissue injury, Rib Fractures, Sternal Fractures, Sternoclavicular dislocations
What are the most common ribs prone to rib fracture?
Ribs 4-9
Which ribs are markers for abdominal injury?
Ribs 9-12 (mobile anteriorly)
Which ribs are markers for severe intrathoracic injury?
1-3
What are the characteristics of a Simple pneumothorax?
- Air in the pleural space
- Affected lung begins to collapse as pleural space expands
- Caused by puncture wound, rib #, or lung defect
What are the signs and symptoms of A Single pneumothorax?
Dyspnea,
Pleuritic chest pain
Tachypnea
Decreased lung sounds
What are the treatments for pneumothoraxes?
Observe
Needle decompression
Chest tube insertion
What happens during a Open Pneumothorax (Sucking Chest Wound) or Communication pneumothorax?
It is due to a Open chest wall injury
Air passes through opening into pleural space and remains outside of lung (preferential if diameter> 2/3 of trachea
Which pneumothorax is characterized by gurgling sound during air movement, bubbling wound, dyspnea, tachypnea, diminished breath sounds?
Open pneumothorax ( sucking chest wound) OR Communicating pneumothorax
What happens in Tension pneumothorax?
Air enters pleural space and becomes trapped – leads to pressure increase.
Increased pressure further collapses lung and shifts mediastinum to unaffected side
What is a Haemothorax?
Accumulation of blood in pleural space
* Generally due to injured lung parenchyma – usually self-limiting
What is the management of a Haemothorax?
A – control airway if necessary
B - Closed-tube thoracostomy to evacuate blood – for all unstable or symptomatic patients
C – restore circulating volume
- Autotransfusion available in some centres.
L- Large volume drainage may necessitate thoracotomy
What are the indications of a Thoractomy?
- Immediate drainage of more than >20ml/kg of blood (> 1500 mls in adult)
- Persistent bleeding >7ml/kg/hour (>200 mls/hr for 2-4 hrs in adult)
- Increasing haemothorax seen on x-ray studies.
- Patient remains hypotensive despite volume replacement.
- Decompensation after initial response to resuscitation.
What is a Tracheobrachial injury?
Blunt or penetrating trauma to chest or neck (30% mortality)
What is the Pathophysiology of Pulmonary contusion?
- Hemorrhage
- Edema
- Progressive accumulation of interstitial fluid
- Hypoxemia
- Decreased pulmonary vascular flow
- Respiratory failure
What is the cause of Pulmonary contusion?
Blunt thoracic trauma
What is the most common form of Blunt cardiac trauma?
Myocardial contusion
What is Pericardial tamponade?
Collection of blood in indistensible pericardium.
What are the clinical features of a pericardial Tamponade?
- Beck’s Triad
-hypotension - distended neck veins (>15mm H20 with hypotension is diagnostic)
- muffled heart sounds (unlikely to be heard in trauma room)
- Pulsus paradoxus – difficult to measure during resuscitation.
- No response to vigorous fluid resuscitation
What are the clinical features of a Diaphragmatic rupture?
- Decreased breath sounds
- Basilar dullness
- Dyspnea
- Bowel sounds in chest
What is Cardiac Tamponade?
A condition characterized by a decrease in cardiac output due to the accumulation of fluid (blood, serous fluid, pus, etc) within the pericardial sac sufficient to restrict the filling of the ventricles .
What is the Primary pathological effect in Tension pneumothorax?
Decreased cardiac output
What are the causes of a Cardiac Tamponade?
- Penetrating Injury (icepick, knife, bullet etc.)
- Blunt Injury with cardiac contusion
- Collagen Vascular Disease (eg. SLE)
- Renal or Hepatic Disease
- Malignancy (pericardial metastases)
- Congestive Cardiac Failure
- Infection (eg. Staph., TB, Viral pericarditis)
- Post Operative (diagnostic tap, heart surgery)
What are the clinical findings?
- Evidence of penetrating injury
- Evidence / history of predisposing condition
- Dyspnoea
- Low-blood pressure, SHOCK
- Distended neck veins
- Quiet heart sounds
- Low-voltage electrocardiogram
What are the treatments for a Cardiac Tamponade?
- Needle Aspiration of Fluid
- Tube Drainage
3.Open repair
What are the causes of Tension Pneumothorax?
- Penetrating Injury with lung damage
- Rupture of pulmonary bulla
- Spontaneous Pneumothorax: Younger patient
- Emphyesema: Older patient, smoker
- Barotrauma
- Scuba Divers, Miners, Firemen, Construction Worker
Iatrogenic: Patients on Ventilators
- Scuba Divers, Miners, Firemen, Construction Worker
What are the clinical signs of a Tension Pneumothorax?
- Dyspnoea
- Distended Neck Veins
- Shock
- Cyanosis
- Mediastinal shift away from affected side.
- Subcutaneous emphysema (air bubbles in tissues).
- Absent or quiet breath sounds
- Hyper-resonant percussion note (drum-like)
True or False? One should perform a Chest X-Ray to determine the diagnosis of a Tension Pneumothorax.
FALSE!! ONE SHOULD NOT NEED A CXR TO CONFIRM THE DIAGNOSIS OF TENSION PNEUMOTHORAX.
What is shock?
Acute widespread reduction in effective tissue perfusion leading to an imbalance in oxygen and nutrients supply and demand
What are the classifications of Shock?
Cold or “Low cardiac output shock”
Warm or “Distributive shock”
What are the types of Cold or “Low cardiac output shock”?
- Cardiogenic
- Obstructive
- Hypovolemic
What are the causes of Cardiogenic shock?
- acute myocardial infarction
- Myocardial contusion
-Severe valvular dysfunction - Congestive Heart failure
- Myocardial contusion
- Vascular disease
What are the causes of Obstructive shock?
- Cardiac tamponade
-Tension pneumothorax - Pulmonary embolism
What are the causes of Hypovolemic shock?
- Haemorrhagic –blood loss
- Non- Haemorrhagic-
Skin- Burns
GI Tract- diarrhoa, vomiting
Kidneys-Diabetes Mellitus, Diabetes Insipidus or Nephrogenic DI, salt losing nephropathy
What is the endotoxin involved with Septic shock?
Lipid A (endotoxin) and Polysaccharide
What is the most common cause of Septic shock ?
Sepsis duuhhh
What is Sepsis?
Sepsis is defined as a ”life-threatening organ dysfunction due to dysregulated host immune response to infection”.
What is an anaphylactic shock?
Extreme reaction to allergen, release of mast cell which degranulate to release Histamine and Bradykinin which causes vasodilation, bronchoconstriction and oedema.
What are the causes of Neurogenic shock ?
Injury to the CNS resulting in loss of sympathetic tone, loss of reflexes below the level of injury and Parasympathetic unopposed leading to Bradycardia and vasodilation causing DECREASED CARDIAC OUTPUT .
True or False? In regards to the pathophysiology of shock, Neutrophil apoptosis may be INHIBITED, enhancing the release of inflammatory mediators.
TRUE!!
True or False? In regards to the pathophysiology of shock, Cellular apoptosis may be AUGMENTED, increasing programmed cell death and thus worsening organ function.
TRUE!!
Circulating beta-adrenergic amines (epinephrine, norepinephrine) also increase cardiac contractility and trigger release of ?
- Corticosteroids from the adrenal gland - this enhances the effects of catecholamines.
- Renin from the kidneys - stimulates volume retention and vasoconstriction.
- Glucose from the liver - Increased glucose increases pyruvate uptake in the mitochondria which increases lactate production when there is insufficient oxygen.
What is one of the most defining features of Septic shock?
Organ failure
Fill in the blanks.” The combination of direct and reperfusion injury may cause ________.”
Multiple organ dysfunction syndrome (MODS)
What is the most frequent target organ in Multiple organ dysfunction syndrome (MODS)?
The lungs
What is the cardiovascular response to Cardiogenic shock?
- Decrease Blood pressure
- Decrease cardiac Output
- Decrease Venous oxygen saturation ( SVO2)
- INCREASE Pulmonary capillary wedge pressure (PCWP)
- INCREASE Peripheral vascular resistance(SVR)
What is the cardiovascular response to Hypovolemic Shock?
- Decrease Blood Pressure
- Decrease cardiac Output due to decrease in intravascular volume & decrease venous return.
- Decrease Venous oxygen saturation ( SVO2)
*Decrease Pulmonary capillary wedge pressure (PCWP) - INCREASE Peripheral vascular resistance(SVR)
What is the cardiovascular response to Obstructive Shock?
- Decrease Blood pressure
- Decrease cardiac Output
- Decrease Venous oxygen saturation ( SVO2)
- INCREASE Pulmonary capillary wedge pressure (PCWP)
- INCREASE Peripheral vascular resistance(SVR)
What is the cardiovascular response to “warm shock”?
*Increased HR
* Increased Stroke Volume
* Increased Venous oxygen saturation (SVO2)]
* Increase Vasodilation
* Increase Cardiac Output
*DECREASED Peripheral resistance (SVR)
* DECREASED Blood Pressure
* DECREASED Pulmonary capillary wedge pressure (PCWP)
True or False ? In Neurogenic shock (warm shock) the Heart rate and Cardiac output is DECREASED.
TRUE!!
What are the basics of an ECG?
Rate
Rhythm
Axis
Intervals
Voltage
ST segments/T waves
What are the diagnostic tools used to diagnose a Cardiac arrhythmia ?
- Electrocardiogram (ECG)
- 24 Hour Holter monitoring
- Exercise testing
- Loop recorder
What are the symptoms of Cardiac arrhythmias?
Palpitations
Precipitants, onset, duration, termination
Weakness
Chest pain
Shortness of breath
Confusion
Lightheadedness
Sudden loss of consciousness (syncope) Transient ischaemic attack (TIA) Cerebrovascular accident (stroke) Sudden cardiac death
What are the signs of Cardiac arrhythmias?
Abnormal pulse
- Weak, absent, irregular, slow, fast
Hypotension
Altered mental status
Syncope
Congestive heart failure
Embolic event (TIA, CVA, peripheral embolus.
What are the symptoms of Angina Pectoris?
- Dyspnea or shortness of breath
- Epigastric discomfort with or without nausea and vomiting
- Diaphoresis or sweating
- Syncope or near-syncope without other cause
- Impairment of cognitive function without other cause
What is Stable Angina?
Chest pain associated with exertion, emotional distress
Relieved by rest
Defined amount of exertion noted by the patient.
What is Unstable Angina?
New onset angina
Worsening angina
Angina at rest
Angina post MI
Angina post PCI
Angina post CABG
What is Prinzmetal’s Variant Angina?
Angina secondary to coronary artery spasm causing obstructive symptoms.
Non-ST Elevated Myocardial Infarction (NSTEMI ) is characterized by?
- Patient who presents with similar characteristics of unstable angina but found to have-
Elevated cardiac enzymes.
Usually due to incomplete/non-obstructive thrombus in the coronary vessel.
What are the primary causes of Cardiomyopathy?
Genetic Disease
- Inherited
- De novo mutation
What are the Secondary causes of Cardiomyopathy?
- Inflammation (myocarditis)
- Drugs
- Systemic disorder
- Infiltrative
- Metabolic/ Storage
- Pregnancy
- Neuromuscular disease
What are the clinical manifest stations of Cardiomyopathy?
- Mechanical dysfunction
- Diastolic/ systolic dysfunction
- Heart Failure
- Mural thrombosis 🡪
- Thromboembolism
- Electrical dysfunction
- Arrhythmias
- Mural thrombosis
- Sudden Death
What are the Morphofunctional types of Cardiomyopathies?
Hypertrophic (HCM)
Arrythmogenic (AC)
Restrictive (RCM)
Dilated (DCM)
HARD
What is the most common type of Cardiomyopathies?
Dilated (DCM)
What is the normal age at presentation of Dilated (DCM)?
20-50
What is the most common valvular heat disease?
Aortic stenosis
What is themes common valvular disease in pregnancy?
Mitral stenosis
What are the causes of Valvular diseases?
Congenital Heart disease
Rheumatic Heart disease
Infections-bacterial endocarditis
Heart attack
Weakening of supporting structures of the heart.
What is Value regurgitation?
The valve doesn’t close all the way so blood leaks backwards due to scarring and retraction of valve leaflets OR weakening of supporting structures.
What is valvular stenosis?
This occurs when the valve leaflets become fused or thickened doesn’t open all the way so not enough blood cases through .
What is the most common Stenosis?
Aortic stenosis
What is the most common regurgitation?
Mitral regurgitation
Which valvular stenosis is associated with a “fish mouth “ appearance ?
Mitral stenosis
What are the clinical manifestations of Mitral stenosis?
Pulmonary congestion
Hemptysis
Fatigue ( low CO)
Oedema ( Right heart failure)
Palpitations
Thromboembolic complications
What is the treatment for Mitral Stenosis?
Anticoagulant
Digoxin, Beta-blockers, rate-limiting calcium antagonists
Diuretic
What are the causes of Mitral regurgitation?
Tear, shortening or elongation of:
Valve leaflets
Chordae tendinae
Annulus
Papillary muscles
What are the clinical features of Mitral regurgitation?
Dyspnea
Syncope
Atrial fibrillation
Weakness
Palpitations
Cough
Paroxysmal nocturnal dyspnea
Lower extremity oedema
Atrial fibrillation
What are the causes of Aortic stenosis?
Congenital leaflet malformations
Rheumatic endocarditis
What are the Clinical features of Aortic stenosis?
S- Syncope
A - Angina
D - Dyspnea
Which valvular diseases is associated with a lough, rough , “crescendo–decrescendo” murmur?
Aortic stenosis
