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Utah / kirklin > Thoracic 2.0 (with infection) > Flashcards

Thoracic 2.0 (with infection) Flashcards

1
Q

Anatomy

Complete course of the Right Vagus Nerve

A
  1. Origin:
    1. nucleus ambiguus,
    2. dorsal motor nucleus,
  2. Exits the base of the skull via the jugular foramen
    1. Descent in the Neck:
    2. lateral to the carotid artery. ,
    3. Remains in carotid sheath through to the thoracic inlet
  3. At the origin of the carotid artery:
    1. the nerve crosses lateral to the bifurcation of the brachiocephalic artery
    2. descends over the anterolateral part of the main stem trachea,
    3. proceeding under the arching part of vena azygos
  4. infra-azygos course:
    1. it lies superficial to the esophagus
    2. between the ascending part of the azygos vein and bronchus intermedius.
    3. then behind the hilum of the lung.
  5. the lower third of the esophagus,
    1. it breaks up and mingles with branches from the left vagus nerve to form the anterior and posterior esophageal vagal plexuses.
  6. Throughout its course in the chest, the vagus nerve remains covered by the mediastinal pleura.
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2
Q

Anatomy- Right vagus nerve:

what are its origins?

where does it exet the skull ?

path in which it descends in the neck?

A
  1. Origin:
    1. nucleus ambiguus,
    2. dorsal motor nucleus,
  2. Exits the base of the skull via the jugular foramen
    1. Descent in the Neck:
    2. lateral to the carotid artery. ,
    3. Remains in carotid sheath through to the thoracic inlet
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3
Q

Anatomy - Right vagus nerve

What is the behavior of the thoracic nerve once it enters the thoracic inlet ?

A
  1. crosses lateral to the bifurcation of the brachiocephalic artery
  2. descends over the anterolateral part of the main stem trachea,
  3. under the arching part of vena azygos:
  • it lies superficial to the esophagus
  • between the ascending part of the azygos vein and bronchus intermedius.
  • then behind the hilum of the lung
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4
Q

Anatomy -

Course of the right recurrent laryngeal nerve

A
  • separates off the vagus nerve at a variable point
  • remains within its sheath (two bananas in one skin).
  • descends parallel to the vagus nerve
  • origin of the right common carotid and subclavian arteries
    • (the terminal divisions of the brachiocephalic artery.)
  • “looping around the distal bifurcation of the brachiocephalic artery”.
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5
Q

Non-recurring RLN

  • prevlance
  • settings in which it is described
A

Non-recurring RLN

  • In 0.5% - 1% of population,
  • described
    1. right-sided aortic arch
    2. retropharyngeal left subclavian artery
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6
Q

What is the impact of a rib fracture on the mortality of a of an elderly trauma patient?

A

65 year old or older are 5x more likely to die from that injury.

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7
Q

Trauma

ECG findings of cardiac contusion vs MI/Thrombus

A
  • ST elevation more associated with MI
  • Non-specific flattening or T wave inversion
    • is more commonly contusion
  • Ventricular arrhythmia are always concerning
  • EKG evidence of Frank MI – need to think about coronary injury – or thombus
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8
Q

Trauma

ECG changes that are criteria for admission?

A
  • New arrhythmia
  • ST segment / ischemic changes
  • Heart block
  • Otherwise unexplained sinus tachycardia
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9
Q

alpha -1 AT Disease

Increase in the risk of pulmonary disease ?

A

in the setting of enzyme deficiency – the risk of pulmonary disease is 20-30x times that of the geneal population

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10
Q

alpha -1 AT Disease

Prevelance in the U.S.?

A

40,000 people of the US

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11
Q

alpha -1 AT Disease

% of the population with emphysema ?

A

1-2% of those with emphysema

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12
Q

Proximal acinar emphysema (Centrilobar )

  • Associated with what disease states ?
A

Proximal acinar emphysema (Centrilobar )

  • Associated with:
    1. Smoking
    2. Inflammation of the distal airways
      *
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13
Q

Proximal acinar emphysema (Centrilobar )

  • is typically located in what parts of the lungs?
A

Proximal acinar emphysema (Centrilobar )

  • Location:
    1. Upper airways
    2. uneven distribution
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14
Q

Panacinar emphysema (panlobular)

A

Panacinar emphysema (panlobular)

  1. Involves the acinus uniformly
  2. Alpha-AT D and PI inhibitor emphysema

Lower lung zones

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15
Q

Interstitial lung disease associated with ptx

A

Interstitial Disease Related to Pneumothorax

  1. Idiopathic pulmonary fibrosis
  2. Eosinophilic pneumonia
  3. Sarcoidosis
  4. Tuberous sclerosis
  5. Lymphangioleiomyomatosis (LAM)
  6. Collagen vascular disease
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16
Q

what side are Catmenial Ptx typically on ?

A

90% are on the right

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17
Q

Ptx associated with AIDS / PCP pneumonia

Hospital mortality ?

A

Overall 50%

Approaches 90% on a ventilator

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18
Q

PTx with AIDS and PCP pneumonia

overall survival

A

months

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19
Q

PTx associated with HIV/PCP

treatment

A

Chemical pleurodesis is ineffective

VATS is preferable

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20
Q

Hemothorax - spontaneous

causes

A
  • Benign
    • Spontaneous ptx
    • Pulmonary AVM
  • Malignant
    • Metastatic melanoma
    • trophoblastic tumor
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21
Q

Spontaneous Hemothorax

Most common malignant causes ?

A

Malignant

  • Metastatic melanoma
  • trophoblastic tumor
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22
Q

size of ptx that is OK to observe

A

if its is < 20%

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23
Q

Signs of a Pneumothorax in the ICU (2)

(i.e. the ventilated patient) ?

A

Signs:

  1. Increasing PaCO2
  2. Decreasing compliance
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24
Q

Pneumothorax in the ICU

what % of ventilated patients devellop a Ptx?

A

Pneumothorax in the ICU

Approximately 1% of all ventilated patients

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25
Q

Pneumothorax in the ICU

At what size of ptx can a Ptx become audible?

A

Breath sounds are audible until a PTx > 50%

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26
Q

Cardiac causes of acute pulmonary edema

A
  1. Failure of mitral repair
  2. paraprosthetic leaks
  3. conduit occlusition
  4. cardiac tamponade
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27
Q

Lifetime risk of ptx in smoking male

vs non smoking male

A

Smoking male: 12%

Non smoking male: 0.1%

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28
Q

Exudate - specific gravity

A

> 1.02

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29
Q

Exudate protein concentration

A

> 2.0g/dl

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30
Q

Light’s Criteria

A

To determine an exudate:

  1. Specific gravity > 1.02
  2. Protein > 2.0g/dl

at least one of :

  1. protein: pleural/serum > 0.5
  2. LDH: pleural / serum > 0.6
  3. LDH: total LDH > 2/3* ULN
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31
Q

Lung Abscess: Medical Treatment

Duration for initial treatment with antibiotics?

A

Lung Abscess: Medical Treatment

Rx: 6-8 weeks of appropriate antibiotics

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32
Q

Lung Abscess: Medical Treatment

% of time medical treatment is effective

A

Result:

90% patients respond to targeted antibiotic therapy alone and do not require surgical intervention

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33
Q

Six Indications for surgery for a lung abscess

A

Indications for surgery

  1. Failed medical therapy
  2. Persistent e_ndobronchial obstruction_
  3. Formation of an empyema
  4. Hemorrhage
  5. BP fistula
  6. Inability to rule out malignancy
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34
Q

Hydatid Pulmonary Disease

Caused by ?

A

Hydatid Pulmonary Disease

Caused by Echinococcus

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35
Q

Hydatid Pulmonary Disease

Presentation:

A
  1. Cough
  2. dyspnea
  3. hemotypsis
  4. Expectoration of cyst material
  5. Acute pleural drainage may cause anaphylactic shock
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36
Q

Pulmonary Hydatid Disease:

Issue with drainage of cyst:

A

Acute pleural drainage may cause anaphylactic shock

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37
Q

Casoni Skin test

A
  • For Hydatid ( Echinococcus skin disease)
  • immediate hypersensitivity skin test
  • intradermal injection of 0.25 hydatid cysts/human cyst
  • Observations made for next 30 mins and after 1 to 2 days
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38
Q

Surgical treatment of Hydatid lung disease

A
  • Avoid spilage
  • Cystectom +/- Anatomic resection
  • May need concurrent liver resection
  • Concurrent liver surgery
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39
Q

Diagnosis of Echinococcus lung infection

A

Diagnosis:

  • Serology (IgM / IgG hemagglutinatioin)
  • Casoni skin test
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40
Q

Pulmonary Amebiasis

Pathophysiolgy

A

Pulmonary Amebiasis

  • Causative organism & Pathophysiology:
    • Entamoeba histolytica
    • Transmitted via the fecal – oral route
    • Liver abscess à ruptures and extends into the surrounding tissues
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41
Q

Pulmonary Amebiasis

Typical presentation

A
  1. Right side chest pain –> radiates to the shoulder
  2. Cough
    • Initially brown and unproductive à becomes purulent chocolate brown sputum
  3. Fever
  4. Malaise
  5. Anorexia
  6. Weight loss
  7. Dyspnea
42
Q

Pulmonary Amebiasis

Cough typical of the infection ?

A

Cough:

  • Initially brown and unproductive
  • becomes purulent chocolate brown sputum
43
Q

Pulmonary Amebiasis

Diagnosis:

A

Parasites found in the sputum (Sputum culture)

44
Q

Pulmonary Amebiasis

Treatment?

A
  1. Metronidazole
  2. Drainage of pleural fluid
45
Q

Pulmonary actinomycosis

  • Organism ?
A

Pulmonary actinomycosis

  • Gram + organism
46
Q

Pulmonary actinomycosis

Presentation?

A
    1. Chest pain
    2. Dyspnea
    3. Hemotypsis
    4. Cough
    5. Fever
    6. Weight loss
    7. Invasion of the chest wall with drainage
47
Q
  • Pulmonary actinomycosis
  • Rx:
A
  • Pulmonary actinomycosis
  • Rx:
    • PCN for 5 weeks
    • Drainage of the plural fluid
48
Q

Characteristic histology of Actinomycosis

A

Sulfur granules

49
Q

What bacteria infections are most commonly related to lung abscesses in hospitalized patients ?

A
  1. Staph
  2. Pseudomonas
  3. Proteus
  4. E. coli
  5. Klebsiella
50
Q

Mycobacterium TB:

Typical anatomic location:

A

Typical anatomic location:

Segmental pneumonia in:

the apical or a superior segment of a lower lobe

Laterality:

Bilateral involvement is rather common

51
Q

Mycobacterium TB

Indications for surgery

A
  1. Massive or Recurrent hemoptysis
    1. >600 cc/24 hrs (massive), severe > 200cc/24 hours
  2. bronchopleural fistula
  3. bronchial stenosis
  4. entrapped parenchyma
  5. failure of medical treatment:
    1. persistent positive cultures with cavitation after 5-6 months of optimal medical therapy with 2 or more drugs
  6. Localized disease with MAI or other atypical myco or MDR
  7. persistent cavitary disease
  8. destroyed lung or lobe
  9. to rule out malignancy.
52
Q

Mycobacterium TB

what is massive / severe hemotypsis

A

massive: >600 cc/24 hrs
severe: > 200cc/24 hours

53
Q

Mycobacterium TB:

what is failure of medical treatment?

A

persistent positive cultures with cavitation after 5-6 months of optimal medical therapy with 2 or more drugs

54
Q

Mycobacterium TB -

Appropriate medical therpay

A

First-line therapy for MTB:

  • 6 months of isoniazid and rifampin
  • with the addition of pyrazinamide and ethambutol for the initial 2 months
55
Q

Extreme multi drug resistant TB:

A
  • resistance to both isoniazid and rifampin
  • Above + resistance to aminoglycosides or capreomycin
56
Q

MTB pericardial effusion:

Best way to make the diagnosis?

A

Pericardial biopsy is used to make the diagnosis

High levels of adenosine deaminase activity in the pericardial fluid are indicative of MTB.

57
Q

What protein is elevated in pericardial fluid associted with MTB ?

A

adenosine deaminase

58
Q

Most common cause of severe hemotypsis

  • what % of cases ?
  • what % require surgery ?
  • how do most people die?
A
  • TB is the most common cause of Severe Hemotypsis
  • TB accounts for 85% of the cases, but only 2% will require surgery
  • MCC of death with severe hemotypsis – is asphyxiation (not hypovolemia)
59
Q
  • Rasmussen aneurysm:
A
  • Seen in the cavity of TB patiens
  • 4% of patients
  • pulmonary artery or arteriole in or near a TB cavity
  • May rupture, causing massive hemoptysis and asphyxiatio
60
Q

Surgery for TB -

what is the operative mortality

A

3-5%

61
Q

Surgery for TB

% frequency of successful clearance?

A

~95%

62
Q

Histoplasmaosis

Typical Environment?

A

Environment: Soil with chicken, pigeon,and bat feces

63
Q

Lung mycotic infection

Environment: Soil with chicken, pigeon,and bat feces

A

Histoplasmaosis

64
Q

Histoplasmaosis

Endemic area?

A

Histoplasmaosis

Endemic area:

  1. Ohio and Mississippi rivers valley
  2. Michigan
  3. Ohio
  4. Indiana
65
Q

Lung mycoplasma infection

Ohio and Mississippi rivers valley

Michigan

Ohio

Indiana

A

Histoplasmosis

66
Q

Sequale of Histoplasmosis

A
  1. Granulomas:
  2. Histoplasmomas
  3. coin-lesions
  4. Fibrosing mediastinitis
  5. Broncholith
  6. Traction diverticulum of the esophagus
  7. Most common benign etiology of SVC obstruction
  8. Chronic cavitary histoplasmosis
67
Q

Most common benign cause of SVC syndrome

A

Histoplasmosis

68
Q

Histology of Histoplasmosis

A

Budding yeast

69
Q

Diagnosis

A

Histoplasmosis -

budding yeast

70
Q

Coccidiomycosis

Geographic distribution

A
  • Mexico
  • Central America
  • Southwest United States
71
Q

Pulmonary fungal infection with Geographic distribution:

  • Mexico
  • Central America
  • Southwest United States
A

Coccidiomycosis

72
Q

Skin manifestation of Coccidiomycosis

A

Erythema nodosum - demonstrates a CMI

73
Q

Syndrome associated with Coccidiomycosis

A

Valley Fever

  1. Pneumonitis
  2. Arthralgia
  3. Typically self-resolved in the immunocompetent host.
  4. Erythema nodosum remains a positive prognostic sign of cell-mediated immunity.
74
Q

Valley Fever

A

Due to pulmonary Coccidomycosis

Pneumonitis

Arthralgia

Typically self-resolved in the immunocompetent host.

Erythema nodosum remains a positive prognostic sign of cell-mediated immunity.

75
Q

Coccidiomycosis - diagnosis

A
  1. serology (IgM or IgG antiboidies)
  2. culture.
76
Q

Long term complications of coccidioimycosis

A
  1. Chronic infection may result in cavitation of lung or formation of granulomatous nodules.
  2. cavities are often located peripherally and may rupture into the pleural spacenwhich results in
    1. effusion
    2. pneumothorax
    3. empyema
    4. bronchopleural fistula.
  3. Peripheral complications:
    • CNS infection
77
Q

Treatment of “Valley Fever”

A

Tx for Coccidiomycosis

  • Tx:
    • Typically self limited
    • Rx:
      • Amphotericin B for severe disease
      • Fluconazole or itraconazole for 3-6 months
    • Surgical intervention:
      1. Failure of medical management
      2. Persistent cavitary lesion
      3. Hemotypsis
      4. Secondary infection
      5. BPF
      6. Persistent cavitary lesion

Differentiate Coccidioides nodules from cancer.

78
Q

Medical therapy for valey fever infection

A
  • Coccidiomycosis
  • Tx:
    • Typically self limited
    • Rx:
      • Amphotericin B for severe disease
      • Fluconazole or itraconazole for 3-6 months
        *
79
Q

Indicaiton for Surgical therapy for coccidomycosis

A
  1. Failure of medical management
  2. Persistent cavitary lesion
  3. Hemotypsis
  4. Secondary infection
  5. BPF
  6. Persistent cavitary lesion
  7. Differentiate Coccidioides nodules from cancer
80
Q

Coddiomycosis - histology

A
  • Spherule containing endospore
81
Q

Lung fungal infection

  • Spherule containing endospore
A

Coccidiomycois

82
Q

Diagnosis ?

A
  • Spherule containing endospore
  • Coccidoiomycosis
83
Q

Blastomycosis - Endemic region

A
  1. Endemic Region:
    1. southeastern and central United States,
84
Q

pulmonary fungus endemic to South East Unitited states

A

Blastomycosis

  1. Causative agent: Blastomyces dermatidis
  2. Endemic Region:
    1. southeastern and central United States,
  3. Tropism:
    1. in the soil and inhaled to cause disease.
  4. Manifestation of Blastomycosis:
    1. pulmonary blastomycosis
      1. flu like symptoms
      2. non-productive cough
      3. Acute pneumonitis
      4. ARDS
      5. Chronic pyogranulomatous lung disease
    2. cutaneous blastomycosis
      1. multiple ulcerated skin nodules in disseminated cases)
    3. Disseminated blastomycosis
85
Q

Manifestations of blastomycosis

A
  1. pulmonary blastomycosis
  2. cutaneous blastomycosis
  3. Disseminated blastomycosis
86
Q

Pulmonary blastomycosis

A
  1. flu like symptoms
  2. non-productive cough
  3. Acute pneumonitis
  4. ARDS
  5. Chronic pyogranulomatous lung disease
87
Q

Cutaneous blastomycosis

A
  1. multiple ulcerated skin nodules in disseminated cases
88
Q

Diagnosis

A

Cutaneous Blastomycosis

89
Q

Broad based budding yeast

A

Blastomycosis

90
Q

Diagnosis

A

Broad based budding yeast - blastomycosis

91
Q

Thymus

Arterial suppy

Veinous drainage

Lymphatic Drainage

A

Blood supply:

  1. IMA

Venous drainage:

  1. Innominate vein
  2. Internal thoracic veins

Lymphatic:

  1. Lower cervical
  2. Internal mammary
  3. Anterior mediastinum
  4. Hilar lymph nodes
92
Q

Thymus - arterial blood supply

A

IMA

93
Q

Thymus - venous drainage

A

Venous drainage:

  • Innominate vein
  • Internal thoracic veins
94
Q

Thymus - lymphatic Drainge

A

Lymphatic:

  • Lower cervical
  • Internal mammary
  • Anterior mediastinum
  • Hilar lymph nodes
95
Q

Most common anterior mediastinal mass

A

Thymoma

96
Q

% of patients with thymoma that have MG

A

30% of patients with thymoma have MG

97
Q

% of patients with Myastheisa Gravis that have Thymoma

A

10-20% of patients with MG have thymoma

98
Q

Association of thymic cancer and MG

A

MG is rare in patients with thymic carcinoma

99
Q

Syndromes related to thymoma

A
  1. myasthenia gravis
  2. RBC Hypoplasia
  3. Hypogammaglobinemia
  4. SLE
  5. rheumatoid arthritis
  6. ulcerative colitis
  7. thyroiditis
  8. Endocrine Paraneoplastic syndromes:
  9. Addisons disease, Hyperparathyroid, panhypopitutiarism
100
Q

Syndromes that are associated with thymoma that have a particularly poor prognosis

A
  1. RBC Hypoplasia
  2. Hypogammaglobinemia

Utah / kirklin (12 decks)

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