Pleura Disease Flashcards by Jeremiah Sokol

Define PTX

Accumulation of air in the pleural space

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Define a tension PTX

A one way valve is developed in the tissue that allows air to enter the pleural space on expiration and not escape.

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How is PTX diagnosed

Imaging

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How is a PTX diagnosed in a urgent situation

Ultrasound

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How is a PTX discovered when it is hard to locate

CT scan

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What effects can PTX have on the thoracic cavity

Mass effect on the lungs

Air trapping can crush the heart

Unilateral chest expansion

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Describe sucking chest wound

As the patient inhales the air enters pleural space and enters subcutaneous on exhalation

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How does puncture to the visceral pleura effect ventilation

Air leaves lung itself and enters pleura and crushes remaining lung on exhalation

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What does eFAST stand for

(Extended) Focused Assessment with Sonography for Trauma

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What is FAST vs eFAST

FAST: a standard tool of trauma assessment

“E” includes inspection of plural space

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Classic site for needle decomposition of tension PTX

Second intercostal space

Trace to midclavicular line

Insert needle superior to rib

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Alternate way to locate classic site for decompression

Locate sternal angle

Trace to intercostal space

Insert needle

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What gauge does EMS use

14
3.25 inches

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What gauge does the hospital use

14
4.5 cm (1.77 inches)

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When do you use alternate insertion sites for decomposition

When the chest wall is >5cm or 2 inches

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What is the alternate site for decomposition/ finger thoracostomy

4th or 5th intercostal space at the anterior axillary line

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Difference between PTX and HTX presentation

HTX:
Chest trauma
Dullness
Tachycardia
Hypotension
Crackles

PTX:
Hyperresonance

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Consequences of HTX

Crushing of lungs and heart

Restrictive lung condition

Compromises O2 delivery

Hypovolemic/hemorrhagic shock

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What is the minimum amount of blood seen on a CXR

Greater or equal to 200-300 mL

(Upright position is better)

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What classifies as acute HTX

300-500mL
(28-32 Fr chest tube)

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Where are chest tubes inserted

4th or 5th intercostal space in mid-axillary or anterior axillary line

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What HTX indicates a massive transfusion

> 1500mL

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What is the risk of >1500mL HTX

Difficulty breathing with shock

Need blood products (saline is not efficient)

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Why can’t saline help with massive HTX

Doesn’t have oxygen carrying capacity or clotting factors

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What fluid can be an effusion

Transudate Blood Pus (empyema) Chyle Cholesterol Tube feed

What organs failing can cause a pleural effusion

Lungs Heart Liver Kidneys Bodies in ability to beat cancer

What is a parapneumonic effusion

Caused by the lungs Associated with bacterial pneumonia Two types: Simple and complicated

Explain a simple parapneumonic effusion

Transudative due to increase in fluid in the pneumonia leaking into the pleura space

Explain a complicated parapneumonic effusion

Fluid from inflammation enters the pleura space with bacteria Can have pus (empyema)

What are the two ways lung failure can cause pleura effusion

Pulmonary embolism: Increased hydrostatic pressure causing R. Heart failure pushing fluid into parietal than pleura Parapneumonic

The ways the heart can cause heart failure

(Increased hydrostatic pressure) Left side heart failure Cor pulmonale

How does the liver cause pleural effusion

Cirrhotic liver fails: Doesn’t make albumin leading to transudate

How does kidney failure cause pleural effusion

Nephrotic Syndrome: Rather than retaining protein it allows it to be peed out.

How does the gastrointestinal system cause a pleural effusion

Failure of lymphatic system can allow chyle to be pushed past diaphragm and enter space.

How does cancer cause a pleural effusion

Non-malignant: Lymphatic vessels are blocked Malignant: Spreads to the pleural space

Why do you need diagnostic test after confirmation of pleural effusion

Usually indicates another disease

Early signs and symptoms of pleural effusion

Dyspnea Pleuritic chest pain Cough

What is pleurisy

An intense inflammation of the pleural surface

What classifies as a moderate pleural effusion

.05-1.5L

What classifies as a large pleural effusion

>1.5L

What feeling accompanies moderate to large pleural effusions

Chest pressure or feeling of fullness

When might you feel Dyspnea with a small pleural effusion

Only if a significant pleurisy is present.

Define a loculated pleural effusion

Trapped in one place and doesn’t follow gravity

Is pale yellow (straw) effusion transudate or exudate

Transudate, some exudate

What does red effusion indicate

Malignancy, trauma

What does white (milky) effusion indicate

Chylothorax or cholesterol

What does brown effusion indicate

Old blood

What does black effusion indicate

Malignancy, aspergilis niger

What are the two rules to confirm exudative nature of pleural effusion

Distinguish transudate from exudate Discover source of the exudative pleura effusion

What are the two test to distinguish exudative from Transudative

Light criteria Three test rule

What protein to serum ratio is positive in the light criteria

> 0.5

What pleural fluid lactate dehydrogenase to serum ratio is positive for the light criteria

>0.6

What pleural fluid LDH is positive for light criteria

>2/3 upper limit of laboratory’s normal serum

How many positive for the light criteria do you need to be exudative

All three

What distinguishes three-test from light criteria

Three-test doesn’t need serum

What’s the principal of pleural effusion management

Treat the underline pathology If there is empyema rid pus

What does self limiting mean

Only exist as lung as the underline pathology is present

What are the two indications for thoracentesis

Diagnostic purposes Therapeutic purposes

What is the maximum amount that can be extracted from a thoracentesis

1.5L Greater amount is associated with reexpansion pulmonary edema

How to position conscious patient for a thoracentesis

Sit up leaning forward

How do you position a unconscious patient for a thoracentesis

On the infected side

How to position for a HTX

Sit up right

How to position for a pleural effusion

Lay down

Steps for a pleural thoracentesis

Clean with antiseptic Anesthetize with lidocaine Administer until the pleural space is reached Use needle to draw out at least 100 mL for or 1.5L for relief

When do you uses chest tube for a pleural effusion

Temporary measure for management

Define pleurodesis

Obliteration of the pleural space

Who gets a pleurodesis

Those who have recurrent pleural disease

What are the three sclerosants used during pleurodesis

Talc Doxycycline Bleomycin

What are the standards of talc

Graded for particle size and cleaned of asbestos Slurry of particles is injected into pleural space

When would you use a tunneled pleural catheter

When the patient has a symptomatic malignant effusion Drains as fluid collects

What are the two types of spontaneous pneumothorax

Primary Secondary

What is a primary pneumothorax

A pneumothorax that has no external cause (Sometimes associated with drugs and increased transpulmonary pressure)

What is a secondary pneumothorax

Casual link to other pathology

What is a bulla

A airspace > 1cm associated with emphysema

What can cause a iatrogenic PTX

Biopsy Central venous catheter Mechanical Ventilation Pacemaker insertion Tracheostomy

Describe a deep sulcus sign

Air pocket at the costophrenic angle when a patient is supine (At the highest point)

What does the visceral pleura look like with a pneumothorax

A white outline

How long can it take for a pneumothorax to be absorbed

Up to 30 days

Define TBI

An alteration in brain function or evidence of pathology that is caused by external forces

What type of TBI requires our care

Diffuse atonal injury Epidural hematoma Subdural hematoma Subarachnoid hemorrhage

Define axonal injury

Brain injury due to shearing of white matter tract On a spectrum: acute, mild and moderate

Symptoms of mild axonal injury

Headache l Confusion Dizziness Memory impairment Blurred vision Behavior change

Symptoms of moderate axonal injury

Repeated nausea or vomiting Slurred speech Weakness in arms or legs Problem thinking or learning

What’s the etiology of diffuse axonal injury

Abrupt acceleration/deceleration creates rotational shear forces that disrupt axons and myelin sheaths

What do we use to see DAI

CT doesn’t work…MRI

What are the three pathologies that involve focal injury

Epidural Hematoma Subdural Hematoma Subarachnoid Hematoma

Where is EDH

Over the dural

Where is SDH

Under the dural

Where is SAH

Under arachnoid layer