Thoracic/CV Emergencies Flashcards
Penetrating Chest Trauma Organs
Heart, Lungs, Arteries/Veins, Pulmonary Hilum, Esophagus, Tracheobronchial Tree
Blood/fluid in pleural space
200-300mL to be visible on CXR
1500 “massive” hemothorax
Penetrating Chest Trauma S/Sx
Hemoptysis Pneumothorax Subcutaneous Emphysema Mediastinal Emphysema Dullness/Absent Breath Sounds
Beck’s Triad
Low systolic/high diastolic (narrowed pulse pressure)
Muffled heart sounds
JVD
Cardiac tamponade
EKG in tamponade: low voltage QRS, electrical alternans
Penetrating Trauma Workup
Helical CT ECHO Angiography Esophogram Bronchoscopy
Procedures in Penetrating Trauma
Right/Left thoracotomy, sternotomy, or clam-shell
Fractures in CT trauma
Rib fractures (1st, 2nd - lot of force) > 3 ribs (on same side) Uncomplicated: tx pain and d/c, pain management, avoid PNA
Associated with significant intrathoracic/intra abdominal injuries: Multiple/displaced rib fx Scapula Flail chest Sternal
Traumatic diaphragmatic hernia
1% admitted blunt trauma
Male > Female
Mostly left, some right, some bilateral
Marked distress, decreased breath sounds, bowel sounds in chest, abd pain, paradoxical respiration
Trans abdominal repair
Pulmonary contusion
First 24 hours Irregular, nonlobular obpacification of pulmonary parenchyma Only some on CT Can progress Pain control, pulm support
PE findings associated with severe ct trauma
Paradoxical chest movement Hypoxia, respiratory distress Seat belt sign Palpable deformity of sternum/ribs Abd tenderness/guarding Hemoptysis Hemodynamic instability Lung sounds changes: absent/decreased, unilateral, bowel sounds
JVD
Tracheal deviation
Hiatal hernia
Paraesophageal: bad
Sliding: eh
Esophageal procedures/tx
Anti-reflux: nissen fundoplication, other options
Achalasia: Nitrate/CCB; surgical: botox, endoscopic pneumatic dilatation, myotomy, esophagectomy
Perforation: HIGH LETHALITY IF MISSED
Most common cause: Iatrogenic
Cervical: instrument
Distal: spontaneous
Hamman’s sign: crunch, raspy sounds synched w/ hr
Acute pain in chest/neck/epigastric; dysphagia, fever, tachypnea, n/v; sub q emphysema, crepitus, seems septic
Large perf/mediatinitis, sepsis, shock –> emergent surgery
NGT maybe, NPO, IVF, Abx
Iatrogenic: medical management
Boerhaave: ETOH, violent vomiting, retching. 10% of perforations. left posterolateral distal. Fatal if not diagnosed
Always operate; still 25% mortality
Dx: CXR (free air), CT, Esophogram w/ gastrograffin
Hempotysis
MCC: bronchitis
PNA, TB, Ca, foreign body (peds), trauma, PE
Bacterial 70%
Dx: PPD, CBC, culture, CXR, CT, Angio
200 mL/day: massive
surg: bronchoscopy, angiography, resection
Spontaneous Pneumo:
Primary: no obv cause (thin tall young men)
Secondary: lung dz
rupture of bleb, secondary to emphysema, cf, tb, ca
less than 30%: O2
more than 30: chest tube
Recurrent: VATS
Tension: emergency; needle to decompress
Do not clamp chest tube
Aneurysm
1.5-2x normal
Cb atherosclerotic, rarely symptomatic
Almost always comorbidities
Thoracic aortic: cb emergency
S/Sx: Compression, pain, hoarseness, regurgitation
Ascending/arch: Sternotomy, may need valve
Descending: left thoractomy or endovascular
AAA rupture: abd pain, pulsatile abd mas, tenderness, hypotension
10 units blood
SBP goal 80-100
ER to OR ASAP (dacron graft, stents)
Cab endovascular if stable or not yet ruptured
Repair: potential complication of IMA ischemia
Aortic dissections - classifications and s/sx
Debakey:
1: both ascending/descending
2: Ascending
3: Descending
Stanford:
A: Ascending/both
B: Distal only
S/sx: Chest/back pain, HTN, neuro changes, distal ischemia, acute failure, varied BP/limbs
Hyptension, shock
High lethality
TRIAD:
1) Abrupt onset of pain (thoracic/abdominal) sharp/tearing
2) Mediastinal/aortic widening on CXR
3) HTN/discrepant BP
Aortic dissections - workup, management
Imaging: Spiral CT (gold), MRI, TEE (may miss distal tears, good for valve eval)
Medical management: Reduce systolic BP (below 100-120)
Decrease LV
B block first( esmolol) THEN vasodilators if necessary
Ascending: Emergent surgery always, high mortality
Complications: rupture, camponade, regurg, ischemia
Descending:
Uncomplicated (no rupture/ischemia): medical
Complicated/failed medical: surgical, endovascular
Transection of thoracic aorta
Blunt chest trauma
Rapid deceleration
Complete: dead at scene, 15% of MVA daths
NOT stable but can look it
Intermittent response to fluid
“funny looking mediastinum”, blurred aortic knob, 2nd rib fx
CXR then spiral CT
Repair: can lead to paraplegia w/ artery of Adamkiewicz
Techniques: open vs endovascular
clamp and run vs bypass
Myocardial contusion
MVA, falls, car/pds, baseball
Similar symptoms to MI: pain in chest, N/V, SOB
Arrhythmia, infarct, ructure
Often Right side of heart
If ok at 48 hours –> can d/c
Serial EKG, tele, enzymes
ECHO
Management pericardial tamponade
AVOID vasodilators (anesthetics, O2, fluids) DRAIN ASAP
Hx: trauma, surg, pericarditis, malignancy
Exam: anxious, inc RR/HR, dec heart sounds, JVD, orthostatic, hypotension
Widened mediastinum
Fluid on ECHO
Acute MI Emergencies
Acute VSD: 2-5 days post MI Often transmural/anterolateral New onset harsh holosystolic murmur, often with thrill Worse hemodynamics Dx with ECHO Urgent surgical repaid
Acute mitral regurgitation
5% of mortality in acute MI
Mean time 13h onset, up to 5-7 days
Papillary rupture (more common with inferior MI; sometimes anteromedial)
Acute pulm edema, pansystolic murmur apex/axilla
Afterload reduction, often surgery
Dressler’s
CABG
Coronary Arter Bypass Graft
1-2 days ICU, then step-down
3-6 day hospital stay
Extubated same day
Foley, chest tubes, Aline, Central line, maybe Swan-Ganz
Dopamine, Milrinone
Alpha agonist - counter vasodilation
NTG - spasm
ASA, anti-coag OR pro-coag, depending on bleeding
CABG complications
constipation depression poor appetite leg swelling infection
Bleeding, MI, low CO, arrhythmia, a-fib (up to 40%), SVT, stroke, changes in cognitive, pulmonary, infection, renal failure, pericarditis, pleural effusions, phrenic nerve damage
Acute mesenteric ischemia - causes
Arterial embolism: 1/3 of cases (secondary to Afib, usually SMA)
Arterial thrombus: 1/3 cases
Progression of pre-existing atherosclerosis
Often 2 vessels
Precipitated by dehydration, hypercoagulable
Venous thrombus:
Hypercoagulable
Non-occlusive:
Severe/prolonged vasoconstriction
Shock / low CO
Iatrogenic alpha agonists, ergots, cocaine
Acute mesenteric ischemia - diagnosis
< 12 hours important
Triad: GI emptying, abd pain, underlying cardiac dz
Limited PE findings
N/V, diarrhea, ileus
leukocytosis, d-dimer, lactate
CT / angiography
Acute mesenteric ischemia - treatment
Papaverine infusion
Surgical embolectomy
Intrarterial thrombolysis
Bypass/reimplantation (esp thrombus)
Maybe 2nd look op
Venous thrombus: may be ok with just anti coag
Acute/subacute/chronic
Aorto-Iliac Occlusive Dz
Acute - emergency
Saddle embolism or in situ thrombosis
Neuro deficits (inc paralysis) Absent femoral pulses (differentiate from spinal cord)
Quick imagine, operate
blue toe syndrome: mini emboli, may herald more severe
Compartment Syndrome
Pallor Pulselessness Parasthesias Paralysis Poikilothermia PAIN
