week 9 Flashcards
classifications of pneumothorax based off primary, secondary and iatrogenic
primary = spontaneous
secondary = underlying disease
iatrogenic = due to medical procedure
symptoms of spontaneous pneumothorax
dyspnoea acute
pleuritic chest pain
tension pneumothorax definition 4 main steps
when a one way valve devlops whereby every breath causes increased trap air
leading to increased intraplueral pressure
mediastinal shift
collapses of vessels
resulting in cardiopulmonary comprimise
risk factors for spontaneous and secondary pneumothorax (age groups, social and family)
PSP: young, skiny, male
SSP: old, underlying lung disease
smoking incl vape and weed
FHx
findings on pneumothorax 4 (2 are key)
trachea can be deviated to opposite side
reduced chest expansion on collapsed side
hyperesonance
reduced/absent breath sounds
investigations for suspected pneumothorax 5
General rule out others
troponin
inflammatory markers
ECG
CXR
Ct
what is the key diagnostic investigation for pneumothorax
CXR
PSP management (haemodynamically stable and haemodynamically unstable)
stable = observation
unstable = tube thorocastomy+drainage
SSP management
tube thorocastomy+drainage
secondary measure if pneumothorax recurrence
pleurodesis
pleurodesis types 2
can be chemical or mechanical
pleurodesis mechanism
triggers inflammation
leads to fibrosis
fills pleural space
what is required for pleurdesis to work? When does it not work?
symphis of visceral and parietal pleura
in non expansive lung there is no symphis
common chemical agent used in pleurodesis
TALC
pleural effusion
air/fluid in pleural space
transudative effusion vs exudative effusion
transudative due to abnomral hydrostatic forces
exudative due to increased capillary permeability
most common causes of transudative pleural effusion 3 (think major body organs)
HF
cirrohosis
PE
most common cause of exudate pleural effusion 3
malignancy
pneumonia
TB
different types of infective pleural effusions 3
para pneumonic
complex parapneumonic
empyema thoracis
parapneumonic effusion 3
no pus
negative cultures
normal pH and glucose
complex parapneumonic
no pus
low pH
potentially culture positive
empyema thoracis
pus
potentially positive culture
mech for development of malignant pleural effusion 2
primary malignancy from mesothelioma
metatstatic pleural spread
most common causes of malignant pleural effusion
breast cancer
lymphoma
mesothelioma
clinical findings in someone with pleural effusion 6
SOB
cough
clubbing
stony dull percusion
redcued/absent breath sounds
reduced chest expansion ipsilaterally
key diagnostic investigations in pleural effusion 2
thoracic ultrasound
CXR
other tests used when investigating an aspirate of pleural effusion 4
pH
glucose = if low maligancy
cell count
cytology
lights criteria in pleural effusion (when used and criteria)
used to determine exudative pleural effusion if one or more of the criteria is met
the criteria are if serum protein, serum LDH or pleural fluid LDH is highly elevated
VATS - video assisted thoracoscopic surgery vs thoracotomy
VATS: less invasive, less complex, reduced post op pain
Thoracotomy: greater access, more invasive, greater visibility
thoracentesis vs tube thoracostomy
throacentesis is a needle aspiration
tube thoracostomy is tube inserted to drain
primary procedure in management of malignant pleural effusion
thoracentesis
symptoms of PE 4
SOB
pleuritic pain
haemoptysis
dizziness
clinical signs of PE
tachypnoea
tachycardia
hypotension
elevated JVP
virchow’s triad
blood stasis
hypercoagulability
vessel wall injury
causes development of venous thrombus event
definition of PE
obstruction of pulmonary artery by thrombus which is either provoked or unprovoked
classifications of PE 3
haemodynamically stable
submassive PE
massive PE
submassive PE characteristics 2
systolic>90 (no hypotension)
RV dysfunction
massive PE characteristics 3
sustained hypotension <90
pulselessness
HR<40
provoking factors for a PE (think what causes clotting) 5
recent immobilisation
smoking
birth control
obesity
cancer
well’s score and what this indicates for D-dier
predicts liklihood of a venous thrombus event
if low do D-dimer test if high proceed to management
ECG signs in PE (all signs of right sided dysfunction)
tachycardia
RBBB
RAD
key diagnostic tool in PE
CTPA - CT pulmonary angiography
what is CTPA
CT pulmonary angiography which visualises pulmonary vasculature
investigations for PE
ECG, ECHO, CTPA, D-Dimer if indicative wells score
management of haemodynamically stable PE
oxygen support
anticoagulation
management of haemodynamically unstable PE
ICU review
thrombolysis considered
drug of choice in anticoagulation of PE
Apixaban
characteristics of pulmonary circulation
low pressure
low resistance
vessels have thinner walls
pulmonary capillaries larger than systemic capillaries
symptoms of pulmonary hypertension 5
SOB
chest pain
syncope
exercise intolerance
fatigue
clinical signs of pulmonary hypertension
raised JVP
systolic murmur
right sided HF
what heart side heart failure is pulmonary hypertension associated with
Left sided
classifications of pulmonary hypertension 5 (the groups)
group 1 = idiopathic
group 2 = associated w heart disease
group 3 = associated w lung disease
group 4 = associated w PA obstruction
group 5 = multiple systems
key cause of pulmonary hypertension
vascular remodelling due to endoethial proliferation or fibrosis
gold standard investigation in pulmonary hypertension
cardiac catheritization
definition of pulmonary hypertension
patients with a mean pulmonary artery pressure>20mmHg
3 pathways of pulmonary hypertension management
endothelin pathway
nitric oxide pathway
protocyclin pathway
endothelin pathway in pulmonary hypertension
block endothelin which causes vasoconstriction
use endothelin receptor anatgonsist
nitric oxide pathway
use medication like nitric oxide to create vasodilatory effect
prostocyclin pathway
prostocyclin analogues which like prostocylcin vasodilate, stop platelets and smooth muscle cell proliferation
prostocylins function 3
vasodilatory
stop platelet agglutination
stop smooth muscle cell proliferation
what is the best maneouvre film to see a pneumothorax
expiratory film
what key radiological feature is evident in pulmonary oedema (hard)
air bronchograms
bochdalek hernia 3 characteristics (whether congenital or acquired and position of presentation)
congenital
bilateral
at the back
morgagni hernia 2 characteristics (whether congenital or acquired and position of presentation)
congenital
middle
hiatus hernia
abdominal content through oesophageal hiatus into upper chest
high risk groups for anaemia
children
pregnant women
women
most common cause of anaemia
iron deficiency
social determinants of anaemia 3
gender = higher in women
lower social economic countries = likely refelects poor diet
geography = poor diet+greater infection
when do you do a d-dimer for pe
when the wells criteria score is less than 4 aka when there is low indication of PE
what is another diagnostic technique you can do for PE and when is this commonly done 4
V/Q scan
do when contraidnications to cTPA including:
- allergy to contrast
- kidney impairement
- pregnant
- children
common ecg findings on a pe and theoretical findings
sinus tachycardia, often nothing else
theoretical finding: is S1Q3T3
in tension pneumothorax does the trachea deviate away from the area of collapse or towards
away
in normal lung collapse can trachea deviate towards or away from collapsed lung
towards
