Surg Block 3 Flashcards
How many compartments are in the mediastinum?
Define Angle of Louis
Superior Anterior middle Posterior
Superior compartment line from T4 to sternomanubrial junction
Utilizing the Burkell Classification, what structures are contained w/in the mediastinum compartments?
Anterior: Thymus Nodes Ascending Transverse Areolar
Middle: Heart Pericardium Trachea Hila Phrenic Areolar
Posterior: Sympathetic Vagus Esophagus Descending
What is the fundamental unit of lung anatomy?
What are the homologous units of the lungs?
Bronchopulmonary segment
L: Lingular segment of upper lobe
R: middle lobe
How many fissures are in the lungs?
Skin tests can be used for Dx what 3 thoracic dzs?
L: single oblique, upper/lower
R: major/oblique= upper/lower
minor/horizontal= upper/middle
TB Histo Coccidio
Purpose of Endoscopy
Purpose of Bronchoscopy
Collect lung tissue; assess vocal cord mobility after suspected lung carcinomas induced voice change
Lymph node sample; obstructions, aspirations, foreign bodies
What is the mainstay method to evaluate the mediastinum?
Where are samples gathered from for this mainstay method?
Cervical mediastinoscopy via incision above sternal notch
Paratracheal levels 2 and 4
Subcarinal level 7
Define Chamberlain Procedure and its use
What is the alternate procedure to the Chamberlain?
Anterior mediastinotomy- node sampling via aortopulmonary window through interspace incision
Video assisted thoracoscopic surgery VATS
How are pleural biopsies acquired?
What is the MC indication and additional benefit to use transthoracic needle biopsy of lungs?
Percutaneous needles
Open surgery
VATS
Solitary pulmonary nodule
Confirm presence of metastatic dz
What procedure is the standard approach for open lung biopsy?
PTs eligibility for this type of procedure depends on their ability to ?
Thorascopy
Tolerant to single lung ventilation
What type of lung sample is used for detecting lung cancer?
How are these samples acquired?
Sputum
Deep cough
Abrasion w/ brush
Bronchial wash
Since CT is the cornerstone to evaluating chest pathology, why would an MRI be used instead?
Why would PET scan be used?
Cancer invasion
Pancoast tumors in sulcus
Staging and workup
More accurate than CT for detection of metastatic caner to nodes
On CXR, ascending aorta should not project farther right than ?
An effusion of what size results in blunted costophrenic angles visible on ? angle?
R atrium
300mL
Frontal CXR
Pleural effusions are sub-divided into ? or ? based on ?
Define the sub-types
Exudate/Transudate
Protein and LDH
Transudate- inc hydrostatic pressure/dec osmotic pressure MC cause: CHF/L HF Hypoalbumin Cirrhosis Nephrotic syndrome
Exudate- due to inflammation
MC cause- malignancy
What is the characteristic CXR finding of pleural fluid?
How much fluid is needed to be visible on PA CXR?
How much is needed to be seen on lateral decubitus?
Meniscus sign
> 150mL
<50mL
How much of a pleural effusion is needed for an attempted thoracentesis?
When pulmonary venous pressure exceeds ? a pleural effusion is formed
1cm thick
> 25mmHg
What part of the lung is involved/spared during pulmonary edemas w/ ? characteristic finding?
Why is cephalization seen in CHF PTs unreliable?
Outer third spared
Lower zones involved w/ bat-wing appearance
Reqs upright image, most CHF PTs are supine
What is a common characteristic in all forms of atelectasis?
What would be seen on CXR w/ atelectasis?
Loss of lung volume
Major/minor fissures shift toward atelectasis
Affected lung inc w/ density
What is the first image of choice for suspected small pericardial effusions?
What are the 4 types of pneumothorax
Pericardial US
Simple- collapsed lung w/ no VS changes; Tx w/ lung expansion
Tension- VS changes, needle-d and thoracostomy
Open- penetrating/sucking wound
Closed- blunt trauma, intact chest wall
How do tension pneumos lead to death?
What will be seen/heard on PE?
Thoracic pressure pushes heart chamber/vena cava leading to CV collapse
Dec sound/fremmitus Tympany on affected side JVD/deviation Tachy/tachy Hypoxic/hypocapnic
All spontaneous pneumothoraces are classified as ?
What is the MC cause of spot-pneumo?
These classically occur most often in ? PTs
Secondary
Ruptured subpleural bleb d/t inc pressure at lung apex of upper lob/superior lower lobe
Asthenic males w/ smoking Hx
Define Catamenial pneumothorax
What is the standard test for Dx pneumothoraxes?
Menstruation related pneumothorax
PA CXR w/ exhalation
How are the different types of pneumothoraxes Tx
All types can become persistent which then need ? Tx
Simple/Closed- thoracostomy
Tension- needle-d, thoracostomy
Open- valve, thoracostomy
Pleurodesis
What is the MC pleural problem?
Pleural effusions are the result of what 5 fluids
Pneumothorax
Sterile fluid Malignant fluid Pus Chyle Blood
Primary pleural tumors are uncommon but ? is common
What are the MC S/Sxs of pleural Dz
Pleural involvement w/ metastatic cancer
Pain Dyspnea
Where is pleural dz pain referred to ? and why?
What movement during PE can produce typical pleuritic chest pain?
Somatic intercostal nerves in chest wall (cervical/costal) and phrenic nerve (diaphragm/mediastinal) leading to chest, back, shoulder pain
Extension of visceral pleura
What are the 7 processes of pathophysiology behind a pleural effusion
Inc pulmonary vascular hydrostatic pressure
Dec vascular colloid oncotic pressure
Inc capillary permeability
Dec intrapleural pressure
Dec lymph drainage
Transdiaphragm movement of abdominal fluids
Rupture of vascular/lymph structures
What will be seen on PE of pleural effusion
What will be seen if it’s an advanced dz
Dec respiratory excursion Dec sounds Dull percussion Friction rubs Local tenderness
Contracted hemithroax w/ narrow intercostal spaces
How much fluid does it take to opacify an entire hemithorax?
What imaging is ordered to evaluate ? types of pleural effusions
Why would a interventional radiology get involved w/ these cases?
2000-2500mL
CT- complex, loculated, recurrent
Loculated pleural effusion
Percutaneous drain placement
What underlying issues can leave mediastinum midline and not shift during development of pleural effusions?
Proximal bronchial obstruction causes atelectasis
Mediastinum fixed from fibrosis/tumors
Ipsilateral lung infiltrated by tumor
Malignant mesothelioma is present
How much fluid is needed for thoracentesis analysis?
What are the criteria for transudates
What are the criteria for exudate?
20mL
CHF/LF
Protein <3g/ration <0.5
LDH <200/ratio <0.6
SpecGrav <1.016
Ca/Pneumonia
Transudates result from alterations in ? and is a ?
Exudates result from alterations in ?
Hydrostatic pressure
Ultrafiltrate of serum
Inc pleural permeability
What is the best location for performing thoracentesis?
What is required after completion of the procedure?
9th/10th intercostal space on mid-scapular line
CXR
When chest tube output falls below ?mL, and lung re-expansion is verified, ? is the next step
How are malignant effusions Tx
200mL/day
Pleurodesis w/ Talc/Doxy
Pallative:
Re-expansion, pleural symphysis w/ 20-28F tube drainage x 48hrs
Pleurodesis
What is the procedure of choice for Dx thoracic empyemas?
How are they Tx
Thoracentesis
Control infection
Removal of fluids
Sterilize/re-expand lung
Eliminate underlying dz
How are hemothoraces Tx
How are chylothoraxes Tx?
32-36F chest tube
Re-expansion, pleural symphysis
Chest tube/Pleurodesis
Low fat diet
What is the MC cause of exudative pleural effusions?
What type of effusion does a PE cause?
Malignancy
Exudative effusion
Define Pyothorax
Define Parapneumonic empyema
Pus in pleural cavity
Underlying suppurative lung dz causing pus in pleural cavity
What microbe is the MC cause of empyema
This is one of the MC complications for ? PTs
Staph A
Staph pneumonia in kids/adults
What Gram Neg microbes can cause empyema?
What other microbes can?
E Coli
Pseudomonas
Klebsiella Pneumo
Proteus
Enterobacter aerogenes
Salmonells
What fungi can cause empyema?
What parasite can cause this?
Aserpgillus
Coccidioides immitis
Blastomyces
Histo capsulatum
E histolytica
What are the typical presenting complaints of PTs w/ empyema
What is the most important non-invasive test for Dx and what is a pathognemonic finding?
What is the procedure of choice for Dx?
Fever Pleuritic pain Dyspnea Hemoptysis Cough
Plain CXR- D-shaped density on posteriorlateral image
Throacentesis
What procedure is done on all thoracic empyema PTs?
Define pulmonary infiltrate
What can cause this
Bronchoscopy- r/o endobronchial obstruction
Consolidaiton; fluid in interstitial space
Pneumonia Pulmonary constitution Inhalation injury Sepsis ARDS- mediators, TRALI, rapid PTX expansion
How can pulmonary edema be reduced?
What is the MC cause of pulmonary capillary leakage or ARDS?
Dec ECF space
Dec hydrostatic pressure in capillary bed
Inc plasma oncotic pressure
Infection/inflammation distant from lungs
How is thoracic empyemas d/t abscesses Tx
When are these PTs considered as surgical possibilities?
An/aerobic coverage x 4-6wks
Percutaneous drainage
ABX failure after 4-6wks
Abscess >6cm
Life threatening hemoptysis/empema/BPF
Bronchial obstruction
If thoracic abscess is causing empyema, what is the preferred procedure?
What is a common post-op issue?
Lobectomy
Pnemonia
