Thorax Flashcards
Where does pain from the parietal peritoneum travel and hence where is it felt
Travels along phrenic nerves
C3,4,5 dermatomes and supraclavicular area
What can happen to the aorta in a deceleration incident
Rupture at the aortic isthmus as this is the junction of mobile to immobile
Arch is immobile due to main branches and ligamentum arteriosum
What is a cardiac tamponade
Accumulation of fluid in the pericardial space that compresses the heart causing reduced diastolic filling and therefore reduced SV
What can cause cardiac tamponade
Penetrating trauma
Aortic dissection
Cardiac wall rupture post MI
How does a cardiac tamponade present
Muffed heart sounds
Hypotension
Distended neck veins
Dyspnoea
Chest pain
Kussmauls sign (paradoxical rise in JVP on inspiration)
Pulses paradoxus (systolic BP drops >10 on inspiration)
Ewarts (bronchial breathing due to left lower lung compression)
What does the ECG show in cardiac tamponade
Low voltage QRS complexes that can vary in height from beat to beat
How is a cardiac tamponade managed
Pericardiocentesis - needle inserted at border of xiphisternum and L rib border aiming for ipsilateral scapula
Thoracotomy
What do changes in leads 1, AVL, V5 and V6 suggest
Lateral MI (left circumflex)
What do changes in leads 2,3 and AVF suggest
Inferior MI (RCA)
What do changes in leads V1 and V2 suggest
Septal MI (LAD)
What do changes in leads V3 and V4 suggest
Anterior MI (LAD)
Which type of MI is associated with bradycardia and why
Inferior
Because the RCA supplies the conducting system of the heart
How is an MI managed
Morphine 10mg IV Oxygen Nitrates (Sublingual GTN spray) Aspirin 300mg oral Clopidogrel 300mg oral
What are the coronary reperfusion options for a patient with an MI
PCI or fibrinolsis
Describe what happens in PCI
Femoral (2cm below inguinal ligament) or radial (2cm proximal to radial styloid process) are used
Seldinger technique is used with a balloon catheter being placed over the guide wire
What are the complications of PCI
Pseudoaneurysm (between tunica media and adventitia) Retroperitoneal haemorrhage (if using femoral) Dissection
What drug is used for fibrinolysis
Reteplase
What are the indications for a lung/hilar twist and how it is done?
Severe lung trauma causing haemorrhage
Divide the pulmonary ligament and anteriorly rotate the lower lobe over the upper lobe to twist and occlude the hilar vessels
Where should a chest drain be inserted
Triangle of safety (pec major, lat dorsi, 5th intercostal space)
On top of the rib (neurovacular bundle sits underneath)
What layers do you go through when inserting a chest drain
Skin, subcutaneous fat, external, internal and innermost intercostals, endothoracic fascia, parietal pleura
What is a flail chest
3 or more adjacent ribs are fractured in 2 or more places leading to paradoxical movement of this segment
How does a flail chest affect breathing
Hypoventilation due to pain
Underlying pulmonary contusions with bleeding and oedema impairing gas exchange
Increased dead space
What is a pneumothorax and the consequence
Air in the pleural space leads to a loss of negative pressure between parietal and viscera pleura so the lung collapses
Compare the 3 types of pneumothorax
Closed - lung or bronchus rupture. Pleural cavity pressure < atmospheric pressure
Open - chest wound with air circulating freely. Pleural cavity pressure = atmospheric pressure
Tension - air enters pleural cavity on inspiration but cannot exit. Pleural cavity pressure >atmospheric pressure
How would a tension pneumothorax present
Chest pain Dyspnoea Distended neck veins Tracheal deviation Tachycardic and hypotensive
How is an open pneumothorax managed
Russel dressing
How is a tension pneumothorax managed
Needle thoracostomy
Chest tube placement in the safe triangle
What is the management of retroperitoneal aortic rupture
EVAR
What is an aortic dissection
Separation of the intima leading to a false lumen within the media
How does an aortic dissection present
Acute tearing or ripping chest pain
BP difference in the arms
Pulse deficit
How is an aortic dissection managed
IV labetalol
EVAR
What are the ECG criteria for coronary reperfusion
ST elevation >2mm in 2 standard or 2 adjacent precordial (chest) leads not including V1
LBBB in patients with other features suggestive of ACS
