Thoracic Surgical Emergencies

Question 1

3 traumatic thoracic emergencies

Answer 1

tension pneumo

• hemothorax
• diaphragm injuries

Question 2

non traumatic thoracic emergencies

Answer 2

esophageal perforation

Question 3

pneumothorax

Answer 3

air in the pleural space

Question 4

tension pneumothorax

Answer 4

positive intrapleural pressure

• accumulated intrapleural air cannot flow back into the bronchial tree. collapse of lung, air is pulled into pleural space causing accumulation and mediastinum+heart deviation
• impared venous return leads to hypotension

Question 6

presentation of tension pneumothorax

Answer 6

any trauma patient with hemodynamic instability. Decreased breath sounds on injured side.

• hyper-resonance on inmaging.
• venous distension of neck veins.

Question 7

JVP change in tensino pneumo

Answer 7

JVP- right atrial pressure. JVP would be higher because pressure in thoracic cavity and lungs is greater. At the same time, there is overall hypo- tension because the heart cannot function properly and overall there is poor perfusion to the rest of the body.

Question 8

note X ray findings of tension pneumo

Question 9

treatment of tension pneumo

Answer 9

don’t wait for XRAY. this is a clinical diagnosis. he needs chest tube but initial needle decompression. plus ABCs

Question 10

hemothorax

Answer 10

definition: blood in the pleural space. source of beleding can be from chest wall, lung, heart/great vessels, diaphragm, intra-abdominal organs spleen/liver

Question 11

diagnostic method for hemothoax

Answer 11

CXR. beware supine CXR can miss large effusions.

Question 12

treatment of hemothorax

Answer 12

1. drainage of blood from pleural space–> chest tube.
2. control of bleeding
   - most pts with blunt trauma/stab will stop bleeding. but you may need surgery if you’ve drained over 1500 ccs of blood.

Question 13

causes of diaphragmatic injury

Answer 13

1. penetrating
2. blunt trauma( multiple rib fractures esp on L side)

Question 14

diagnostic CXR findings of diaphragm injuries

Answer 14

• Diagnosis
– Can be difficult to detect

• CXR
– Elevated hemidiaphragm /indistinct
– NG appears in chest / Hollow viscous in chest •

CT Scan with Coronal Reconstruction
– Now test of choice

Question 15

treatment for injury to diaphragm

Answer 15

1. surgical repair: natural history of undiagnosed is enlargement)
   - thoracotomy for chronic injury

Question 16

classic presentation for an esophageal perforation

Answer 16

“chest pain after vomiting or endoscorpy”

• subcutaneous emphysema in neck

Question 17

auscultative findings of esophageal perforation

Answer 17

mediastinal crunch (air in pericardium)

Question 18

CXR findings of esophageal perforation

Answer 18

air in mediastinum/neck

• pleural effusion
• hydropneumothorax.

Question 19

diagnostic procedure for esophageal perforation

Answer 19

• water soluble contrast swallow followed by thin barium if negative
• confimrs diagnostic.
• confirms location.
• helpful in selection of treatment.

Question 20

Not all esophageal perforations need surgical management. what is the criteria for non-operative management?

Answer 20

• no sepsis
• contained leak
• drains back to the esophagus
• cervical
• extensive esophageal cancer..

then you treat NPO, IV Abx, nutritional support.

Question 21

Boerhaave’s syndrome

Answer 21

postemetic rupture

• classic location of tear is just above the gastroesophageal junction with ruptue into the left plueral space. requires surgical treatment.

Question 22

Boerhaave’s syndrome is:

___ rupture

• classic location of tear is just above the __ ___ with ruptue into the left __ ___. requires surgical treatment.

Answer 22

postemetic rupture

• classic location of tear is just above the gastroesophageal junction with ruptue into the left plueral space. requires surgical treatment.

Question 23

prognosis of esophageal perforation is dependent on location of tear. explain.

Answer 23