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PPNP 3 > Respiratory emergencies QUIZ Wk10 > Flashcards

Respiratory emergencies QUIZ Wk10 Flashcards

1
Q

3 types of pneumothorax

A

Closed, open, tension(needle decompression)

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2
Q

What is a pleural effusion

A

Abnormal accumulation of fluid in pleural cavity

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3
Q

Types of pleural effusion

A

Transudative pleural effusion
Exudative pleural effusion
Hemothorax

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4
Q

What is transudative pleural effusion caused by

A

Cardiac failure
Hypoalbuminemia eg nephrotic syndrome. liver disease, protein malnutrition

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5
Q

Etiology of pleural effusion (traumatic)

A

 Blunt trauma
 Penetrating trauma (including iatrogenic)

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6
Q

Etiology of pleural effusion (non-traumatic/spontaneous)

A

 Neoplasia (primary or metastatic)
 Blood dyscrasias, including complications of anticoagulation
 Pulmonary embolism with infarction
 Torn pleural adhesions in association with spontaneous pneumothorax

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7
Q

Pathophysio of pleural effusions

A

Small effusions – no symptoms
 Minimum of 300 ml in the pleural cavity to be seen in the x-rays (costophrenic angle)

Large effusions
 Interferes with lung expansion with
reduction in vital capacity
 Hypoxia and hypercapnia

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8
Q

Clinical features of hemothorax

A

Acute pleural pain, dyspnea

Small effusions
 No findings or shifting dullness on percussion

Large effusions
 Decreased chest movements
 Shift of mediastinum structures
 Dullness on percussion breath sounds

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9
Q

Treatment of hemothorax

A

If a hemothorax is equal to or greater than the
amount required to obscure the costophrenic
sulcus or is found in association with a pneumothorax based on chest radiograph findings, it should be drained by tube thoracostomy

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10
Q

What is pneumothorax

A

 Collection of air in pleural cavity

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10
Q

When should surgical exploration in cases of traumatic hemothorax be performed

A

 Greater than 1000 mL of blood is evacuated immediately after tube thoracostomy. This is
considered a massive hemothorax.
 Bleeding from the chest continues, defined as 150-200 mL/h for 2-4 hours.
 Persistent blood transfusion is required to maintain hemodynamic stability

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11
Q

Types of pneumothorax

A

spontaneous / chest trauma

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12
Q

cause of Spontaneous pneumothorax

A

 Rupture of bulla(e) on surface of lungs
 Bronchial asthma, COPD, tuberculosis

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13
Q

why chest trauma results in pneumothorax

A

 Negative pleural pressure will allow air to enter

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14
Q

Clinical features of pneumothorax

A

Acute pleural pain, dyspnea in large pneumothorax
 Decreased chest movements
 Shift of mediastinal structures
 Hyper-resonance on percussion and absent breath sounds

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15
Q

Tension pneumothorax arises from progressive _____ of a simple ______

A

 Arises from progressive worsening of a simple pneumothorax

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16
Q

Tension pneumothorax is associated with formation of a _______ at point of _____ in the lung

A

Associated with formation of a one-way valve at point of rupture in the lung

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17
Q

In tension pneumo, air becomes ___ in ______ and builds up which:

A

 Air becomes trapped in pleural cavity and builds up -> Prevents lung from inflating fully

18
Q

What is tension pneumo?

A

Tension pneumothorax: The accumulation of
air under pressure in the pleural space.

The air enters the pleural cavity and is trapped there during expiration so the air pressure within the thorax mounts higher than atmospheric pressure, compresses the lung,
may displace the mediastinum and its
structures (including the lung) toward the opposite side, and cause cardiopulmonary impairment (decrease cardiac output)

19
Q

Tension pneumo causes collapse of ___ and shift of ___ structures

A

Causes collapse of lung and shift of mediastinal structures

**CVS collapse due to poor VR (venous return)

20
Q

Complications of pneumothorax

A

 Venous return and cardiac output decrease with
hypotension and tachycardia
 Hypoxemia due to alveolar collapse
 Reexpansion pulmonary edema
 Bronchopleural fistula - Bronchopleural fistula (BPF)
is a sinus tract between the main stem, lobar, or segmental bronchus and the pleural space

21
Q

Diagnosis of pneumothorax

A
  • Chest radiography
    – Requires good quality film
    – In ICU, 30% of pneumothoraces are missed due to:
  • Low-quality film
  • Supine position of patient on AP film
  • Air hidden behind thoracic or mediastinal structures
     Radiographic appearance
     Mediastinal shift, diaphragmatic depression, flattened ribs

CT scan - used to confirm size and presence of pneumothorax.

22
Q

What is reexpansion pulmonary edema?

A

Occurs following rapid lung reexpansion particularly:
 From low lung volumes
 Long duration pneumothorax
 High pressure gradient across lung

May be related to reperfusion injury

Lung reexpansion should be slow
* First, just waterseal, no suction
* If lung fails to reexpand, then apply suction

23
Q

Medical mgmt of pneumothorax

A
  1. Oxygen
    – Should be administered to all patients
    – Supplemental O2 speeds absorption of air from pleural space
  2. Observation of stable patients
    – Primary: observe 4 hours, if no enlargement: home
    – Secondary and iatrogenic: hospitalize and observe carefully,
    * If there is any deterioration (SpO2, RR, etc) - drain
  3. Simple aspiration
    – Small catheter placed in pleural space
    – Connect to three-way stopcock
    – Slowly evacuate until no more air can be removed
    – This works as many leaks heal between time of leak and its
    drainage.
    – If 4 L air is removed without resistance, chest tube placement is
    required
  4. Chest tubes
    – Resolution is mostly determined by lung healing
    – Small bore: placed via small incision in second intercostal space
    (ICS), midclavicular line or laterally, fifth–seventh ICS
    * Connected to underwater seal or Heimlich valve
    – Large bore: placed via blunt dissection, usually connected to
    “three-bottle” chest drainage system
    – Chest tubes are sutured in place
  5. Pleurodesis
    – consider with recurrent
    pneumothoraces
24
Q

When is chest tube placement required in pneumothorax?

A

– If 4 L air is removed (thru simple aspiration) without resistance, chest tube placement is required

25
Q

What is pulmonary edema?

A

 Life threatening emergency in which excess fluid
accumulates in lungs
 Characterized by extreme breathlessness
 Due to alteration of capillary forces in the alveolar wall

26
Q

Causes of pulmonary edema

A

Increased Venous hydrostatic pressure
 LVF (most common cause)

Decreased Plasma osmotic pressure
 Hypoalbuminemia

Altered alveolar capillary membrane
permeability
 Acute respiratory distress syndrome (ARDS)

27
Q

Pathophysio of pul edema

A

Increased pulm capillary pressure
 Engorged vessels, lungs less compliant
 Increased resistance of small airways (Tachypnoea, wheezing)

If pressure ↑ > 25mmHg (normal 15)
 Increased filtration of fluid into interstitial space , causing interstitial edema
 Gas exchange worsens
 Xray changes –Kerley B lines

Accumulation of fluid disrupts intercellular membranes
 Leads to collection of fluid in alveolar spaces
 Alveolar edema

28
Q

Clinical features of pul edema

A

 Anxiety, profuse
perspiration
 Acutely breathless
 Tachypnea, tachycardia
 Wheezing, crepitations
 Cough
- Productive of frothy, blood-tinged sputum
- Can be copious

29
Q

What is PULMONARY EMBOLISM

A

 Blockage and obstruction of a
pulmonary vessel by a blood-borne
substance
 Common cause of unexpected death
 Often missed as symptoms are often
non-specific

30
Q

causes of pul embolism

A

 Thrombus (most common)
 Air
 Fat
 Amniotic fluid
 Parasites
 Septic emboli
 Tumor (renal cell Ca with secondaries to ivc)

31
Q

Risk factors of pul embolism

A

Virchow’s Triad
1. Venous stasis
 Prolonged bed rest
 Immobilization
 Low CO
 Pregnancy
2. Hypercoagulability
 Tissue injury after surgery, trauma
 Malignancy
3. Vessel wall inflammation

32
Q

Pathophysio of pul embolism

A

 Normally, microthrombi form and are
removed continuously in venous
system
 Pulmonary vessels act as filters (Remove small emboli from reaching arterial system)
 Large clots can damage lung/heart
function
 > 95% arise from thrombi in deep
veins of LL

Hemodynamic changes
 Obstruction causes ↑ in pulmonary P
 RV strain if embolus is large or pre-existing heart disease -> Decreased CO
 Large embolus occludes pulmonary bld flow -> No CO -> Sudden death

Change in V/Q ratio
 Perfusion distal to obstruction ↓ -> Results in compensatory
hyperventilation initially

Eventually, hypoxemia causes ischemic damage to alveolus
 Alveolar collapse -> Pulmonary edema -> ↓ surfactant -> Release of inflammatory chemicals

Pulmonary infarction
 Occurs in 10% of cases

33
Q

Clinical features of pul embolism (SMALL emboli)

A

 effort dyspnoea
 tiredness
 syncope
 cardiac arrhythmias

34
Q

Clinical features of pul embolism (MASSIVE emboli)

A

 Sudden severe central chest pain
 Marked tachypnea, dyspnea
 Shock

35
Q

Clinical features of pul embolism (in general)

A

Classic triad of sudden onset of
 Dyspnea, pleuritic pain, hemoptysis
 20% of patients

Swollen, tender, warm calf

Auscultation
 Inspiratory crackles
 Pleural rub
 Wheezing

ECG
 Sinus tachycardia
 S1Q3T3 - Deep S in lead I, Q wave, inverted T in lead III

36
Q

The percussion of chest of chest on the patient would reveal a dull percussion. What would be your impression if the dull percussion note changes to hyper-resonant percussion?

A

Tension pneumothorax

Dull percussion: usually due to presence of fluid (hemothorax)

In normal lungs: expected percussion note should be resonant

In simple pneumothorax: Percussion note will also be resonant

In larger pneumothorax (e.g. tension pneumothorax): Percussion note will progress to hyper-resonant

37
Q

What is the best initial test in the diagnosis of hemothorax?

a. CXR
b. Chest ultrasound
c. CT scan
d. CT angiography

A

CXR

38
Q

What is the definitive test in diagnosing hemothorax?

a. Chest CT scan
b. CXR
c. Chest ultrasound
d. MRI

A

Chest CT scan

39
Q

What are the causes of spontaneous hemothorax?

a. RTA
b. An accidental knick during a CTVS surgery
c. metastasis to the pleura
d. Pulmonary embolism

A

Metastasis to the pleura

40
Q

Which of the following are potential life-threatening complications
that can occur in massive haemothorax if the blood is allowed to retain in the pleural space?

a. Hemopneumothorax and obstructive shock
b. Septic shock and lung atelectasis
c. Cardiogenic shock and cardiac failure
d. Mediastinal spread and septic shock

A

Septic shock and lung atelectasis

41
Q

What should you do to avoid damaging the
neurovascular bundle (Intercostal vein,
artery and nerve (in this order)) during
insertion of the chest tube?

a. Avoid the upper border of the rib while inserting the chest tube
b. Avoid the lower border of the rib while inserting the chest tube
c. Local anesthesia will prevent injury to the neurovascular bundle
d. Inserting the tube in the anterior axillary line will avoid any neurovascular damage.

A

Avoid the lower border of the rib while inserting the chest tube

42
Q

Which of the following treatment options is suitable if the chest tube drainage shows clear fluid instead of blood like substance and the drainage amount continues to increase?

a. Pleurodesis
b. Thoracotomy
c. Continue with Chest tube drainage
d. CT guided aspiration of pleural fluid

A

Pleurodesis: a procedure in which pleural space is artificially obliterated. Involves the adhesion of the 2 pleurae.

1500cc

PPNP 3 (19 decks)

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