Unit 4 Case 1: Pneumothorax Flashcards
bacterium in bovine tuberculosis
mycobacterium bovis
is tuberculosis a notifiable disease
yes
transmission of bovine tuberculosis
unpasteurised products
inhaled and infected droplets
direct contact of salvia
urine
faeces
types of tb you can have once infected
active or latent
what is a notifiable disease
disease by law that must be reported to the government authorities
human tb and bovine tb
similar symptoms
clinicians might not be able to tell the difference between the two when presented in people
how to treat Tb
rifampicin
isoniazide
pyrazinamide
ethambutol
6 month treatment
what is latent tb
not infectious to other a
how do you detect tb
x ray
Mantoux test
microscopy of sputum
biopsy
symptoms of tb
cough
weight loss
night sweats
high temperature
swelling around your neck
public health impact of TB presence in dairy farming
must isolate the infected animals and now allow their products to leave the farm, reduced income
cows have had to be slaughtered to prevent the spread
zoonotic disease
prevention and control measures of bovine TB
increased surveillance
post mortem inspection
individual testing
treatment (but is expensive)
badger culling as easily spread by badgers
normal mechanism of inspiration
external intercostals contract
diaphragm contracts and flattens
atmospheric pressure is greater than pulmonary pressure
air moves into the lungs
ribs and sternum are elevated, extending the anterior/posteriro dimension of the thoracic cavity
extension of the superior.inferior dimension of the thoracic cavity
normal mechanism of expiration
external intercostals relax
diaphragm relaxes
pulmonary pressure is greater than atmospheric pressure
air is forced out of the lungs
depression of the ribs and the sternum, reduces the anterior/posterior dimension of the thoracic cavity
volume of the thoracic cavity decreases
accessory muscles of forced inspiration
scalenes
sternocleidomastoid
pectoralis major and minor
serratus anterior
accessory muscles of forced expiration
anterolateral abdominal wall
internal intercostals
innermost intercostals
mechanism of paradoxical breathing
when the diaphragm moves in the opposite direction to the thoracic cage
as the diaphragm fatigues moves upwards in response to the negative intra-thoracic pressure generated by the inspiratory action of the neck and intercostal muscles
causes chest to contract during inhaling and expand during inhaling
cause of paradoxical breathing
diaphragmatic dysfunction
what may give an increased likelihood of paradoxical breathing
obstructive sleep apnea
disruption of nerves
mineral deficiency
weak respiratory muscles
obstruction of the chest wall
obstructive sleep apnea
disruption of the inflow of oxygen and exhalation of carbon dioxide
eventually chest wall will turn inwards rather than outwards
nerve damage
to the phrenic nerves by MS
muscular dystrophy and lung cancer
mineral deficiency
potassium
magnesium
calcium
weak respiratory muscles
MS and ALS which are neuromuscular conditions
obstruction of the chest wall
can separate the ribs
meaning will no longer expand when you inhale
this section can start to push inwards which causes paradoxical breathing
testing for paradoxical breathing
fluoroscopy
pulmonary function test
maximal static inspiratory pressure
sniff nasal inspiratory pressure
scans for paradoxical breathing
ultrasound
chest x ray
electromyography
CT scan
MRI
treatment for paradoxical breathing
treat underlying condition
can prescribe to alleviate the symptoms
nocturnal invasive ventilation
continuous positive airway pressure
surgery
surgical plication
phrenic pacing
testing for resonance
Firmly place middle finger over the chest wall along intercostal space
Tap chest along interphalangeal joint with middle finger of other hand
Tap 2-3 times in a row
Listen to feel the resonance
Percuss all around the chest
Patient cross arms to shoulder to expose posterior thorax
Tap top to bottom and compare by percussing corresponding spaces
Hands over head and percuss the axilla
Move from and percuss anterior chest clavicle and supraclavicular space
normal resonance
dullness of left anterior chest due to heart and right lower chest due to liver
hyperresonance of left lower anterior chest
due to air filled stomach
increased resonance
lung distension in asthma
bullous disease
emphysema
can be due to pneumothorax
when would an air ambulance be used
there is a criteria followed called helicopter emergency medical specialist
when else may an air ambulance be used
interhospital transfer and non-urgent scene transfer
when will the land ambulance be dispatched alongside the air ambulance
to ensure safe movement of the patient to the aircraft
may be weather restrictions
refusal of the patient to fly
flight safety
aggressive patietns
role of the air ambulance
can give pre-hospital life saving care to the patient at the scene
crew on board will be capable of life saving procedures such as giving general anaesthetic and open-heart surgery
then take patient to a trauma centre/hosital
what are trauma centres equipped to deal with
most serious conditions:
car accident injuries
gunshot wounds
brain injuries
stab wounds
serious falls
blunt traumas
effect of being in a rural environment on emergency medicine
long distance from specialist treatment
longer times for ambulances to reach the patient and unequal modern healthcare
reduced primary care services for after emergency treatment
car accidents more likely in rural areas, more serious conditions in hard-to-reach locations
farms in rural areas are associated with increased levels of occupational injury, illness and death
process of a primary trauma survey
Airway
breathing
circulation
disability
exposure
airways examination
check airways noises
position of head
foreign body
fluid, secretions
oedema
airways intervention
open
suction
secure
o2
airways goal
patent airway
breathing examination
look listen feel
respiratory rate and effort
breath and added sounds
subcutaneous emphysema
symmetry of chest movement
tracheal deviation
jugular vein distension
cyanosis
breathing intervention
o2 according to spo2
pneumothorax therapy
inhalation therapy
ventilation
breathing goal
sufficient oxygenation and ventilation
circulation examination
heart rate
blood pressure
capillary refill time
bleeding
skin colour
blood sample
diuresis
circulation intervention
IV/IO access
control of bleeding
massive haemorrhage protocol
fluids
drugs
transfusion
circulation goal
stabilisation of circulation
disability examination
AVPU/GCS
reactivity and symmetry of pulls
blood glucose levels
basic neurological examination
posture
toxicological examination
disability intervention
glucose
antidotes
disability goal
evaluation of neurological state
exposure examination
head to toe examination
medical history
temperature
injuries
oedemas
scars
signs of drug abuse
skin changes
signs of infection/sepsis
exposure intervention
identified cause therapy
thermomanagement
trauma treatment
insertion of NGT, IUC
exposure goal
revealing other symptoms and therm-management
who is involved in the trauma team
team leader
primary physician
airway team
trauma nurses
radiographer
social worker
scribe
surgeons
primary aim of the trauma team
to rapidly resuscitate and stabilise patient
team leader role
uses trauma checklist
allocate roles
ensures PPE is worn prior to arrival of patient
identifies estimated weight
document
handover
primary and secondary survey
primary physician role
primary and secondary survey
airway team role
anaesthetist
nurse
trauma nurses role
ECG
oximetry
BP
IV access
remove clothes
draw blood
social worker role
talk to the family
provide support/guidance
scribe role
records time of patient arrival
Jesus steps
vital signs
name of staff in attendance and their roles
different types of oxygen masks
nasal cannula
Hudson mask
bag valve mask
venturi mask
non-rebreather mask
non-invasive ventilation
invasive ventilation
nasal cannula
24-30% oxygen
flow rate 1-4L, 2L is most comfortable
used in non-acute situations
Hudson mask
rarely used
30-40% oxygen
flow rate 5-10L per minute
bag valve mask
handheld
flow rate 15L per minute
venturi mask
delivers 24-60% oxygen
different colours for different flow rates
blue 2-4
white 4-6
yellow 8-10
red 10-12
green 12-15
non-rebreathe mask
85-90% o2
15L flow rate
bag contains valves to prevent rebreathing of expired air
used for acutely unwell patients
2 types of non-invasive ventilation
continuous positive airways pressure
bilevel positive airways pressure
continuous positive airways pressure
high pressure air/oxygen with a tight fitting mask
positive pressure all the time to keep airways open
used in acute pulmonary oedema and sleep apnoea
bilevel positive airways pressure
high positive pressure on inspiration and lower positive pressure on expiration
used on exacerbations of COPD and ARDS
what is the definition of a pneumothorax
air in the pleural cavity
between the parietal and visceral pleurae resulting in lung collapse
primary spontaneous pneumothoraces
usually occur due to rupture of the pleural bleb
secondary spontaneous pneumothoraces
occur in due to pre-existing diseases
e.g. COPD, infection, cystic fibrosis
traumatic pneumothorax
result of a blunt or penetrating trauma
what are the types of pneumothorax
primary spontaneous
secondary spontaneous
traumatic
pleural bleb
small collection of air between the lung and the visceral pleura usually found in the upper lobe of the lung
due to sub pleural alveolar rupture and congenital defects in connective tissue of alveolar walls
what is COPD
chronic obstructive pulmonary disease
includes emphysema and chronic bronchitis
iatrogenic pneumothoraces
traumatic pneumothoraces caused by clinical instrumentation to the thorax
describe a tension pneumothorax
high pressure air accumulates in the intrapleural space and isn’t able to completely exit during expiration putting pressure on and displacing the mediastinum
causes lung to collapse on ipsilateral side
pressure increases it causes the mediastinum to shift to the contralateral side, contributes to hypoxemia
symptoms of patients with a pneumothorax
chest pain, worsens when breathing
breathlessness
mild symptoms and pneumothorax of less than 2cm will be discharged and out patient follow up
testing for a pneumothorax
plain chest x ray
ct scan
ultrasound
what is in the image
pneumothorax
when may a chest x ray not be useful in diagnosing a pneumothorax
if there is a small pneumothorax
or the air is collecting anteriorly it may be missed
when may a CT scan be used for a pneumothorax
to produce a more detailed image
to find the cause or diagnose a pneumothorax that may not have been spotted by x ray
what will an ultrasound of a pneumothorax show
grainy below the pleural surface in a healthy individual due to lung movement
however, in an individual with a pneumothorax lung sliding would be invisible due to air blocking transmission of the ultrasound wave
what is a flail chest segment
when 3 or more ribs are broken in at least 2 places
causes a segment of the chest wall ti move independently of the rest of the chest wall
normal ph of blood
7.35-7.45
normally paO2
75-100 mmHg
normal PaCO2
35-45mmHg
normal value of HCO3
22-26 mEq/L
normal O2 sats
95-100%
metabolic acidosis
decreased pH
increased H+
primary disturbance is decreased HCO3-
secondary response is decreased pCO2
metabolic alkalosis
increased pH
decreased H+
primary disturbance increased HCO3-
secondary response is increased pCO2
respiratory acidosis
decreased pH
increased H+
primary disturbance increased pCO2
secondary response increased HCO3-
respiratory alkalosis
increased pH
decreased H+
primary disturbance decreased pCO2
secondary response decreased HCO3-
causes of tracheal deviation
tension pneumothorax
pleural effusion
mediastinal goiter
pleural fibrosis
atelectasis
pulmonary fibrosis
pneumonectomy
mediastinal lymphoma
what is a chest drain
flexible tube inserted through the chest wall into the pleural cavity
through the 5th intercostal space
guided using real time ultrasound
risks/side effects associated with a chest drain
pain
failure of procedure
bleeding
infection
damage to surrounding structures
pneumothorax
what is a chest drain used to do
remove air/fluid from pleural space
prevent air/fluid returning to the pleural space
restore negative pressure in the pleural space
what are the two types of drain
seldinger
surgical
seldinger chest drain
commercially packed kit
needle and syringe inserted into chest cavity
air aspirated to confirm needle is within the pneumothorax
guide wire inserted
needle removed
skin incision made around wire
dilated passed over guide wire
dilater removed
drain inserted over guide wire
guide wire removed
surgical chest drain
incision made with scalpel, 2-3 cm
curved blunt dissecting instrument used to go through tissues down to the parietal pleura
finger sweep using index finger
place drain
secured with non-absorbable sutures and a purse string stitch
drain connected to underwater seal drainage bottle so air doesn’t re-enter and can apply suction to drain
chest x ray done to confirm correct positioning
types of mechanical ventilation
negative pressure
positive pressure
negative pressure ventilation
attempts to mimic functions of respiratory muscles
applies sub atmospheric pressure outside of chest to inflate the lungs
advantages of negative pressure ventilation
upper airway can be maintained/no need for endotracheal tube
patients can talk and eat
fewer psychological disadvantages
disadvantages of negative pressure
abdominal venous blood pooling
primarily replaced by positive pressure ventilators (mask, nasal device, tracheostomy tube)
positive pressure ventilation
mechanical ventilator moves air into patients lungs via an endotracheal tube or mask
inflating pressure during respiration (proximal airway) equals the sum of pressure required to overcome the compliance of the lug and chest wall and the resistance of the airway
2 types of positive pressure
positive end-expiratory pressure
continuous positive airway pressure
treatment options for pneumothorax
needle aspiration
chest drain
supplemental oxygen therapy
non-surgical repairs
surgery
complications of intubation
upper airway trauma
tooth displacement
injury to mouth, throat, vocal cords and trachea
sinusitis
tracheal narrowing
tissue death
infection
pneumonia
sepsis
complications of ventilation
alveoli rupture
lung collapse/pneumothorax.
oxygen toxicity
pneumonia
medication side effects
ventilator malfunction
inability to wean off ventilation
to give consent what must you be able to do
understand, remember, use it and communicate that decision
where it is not possible to gain consent, doctors should provide treatment that is in the patients best interests
can include to save a life or avoid a significant deterioration to the patients health
main painkillers and sedations
opioids are medicines used to treat pain
work by attaching receptors in the brain and spinal cord, gut and other parts of the body
lowers the feeling for pain
weak opioids
codeine and dihydrocodeine
strong opioids
tramadol
methadone
diamorphine
morphine
fentanyl
oxycodone
emotional and psychological responses to trauma
denial
anger
fear
sadness
guilt
hopelessness
irritability
anxiety
depression
may have emotional outbursts
flashbacks and nightmares
trauma can also cause physical symptoms such as headaches, fatigue, sweating, feeling jumpy and racing heart
hyperarousal
what is PTSD
anxiety disorder triggered by a terrifying event
may start 1 month after or years after event
4 groups of PTSD symptoms
intrusive memories
avoidance
negative changes in thinking and mood
changes in physical and emotional reactions
psychological impact of PTSD on family
sympathy
negative feelings
avoidance
depression
anger
guilt
health problems
