SYB Marni Scheiner MS IV Marni Scheiner MS IV

Case HPI: 78 yo M, brought to ED by ambulance in complete cardiac arrest. Patient was with his family out to dinner, and suddenly became unresponsive, fell from sitting position. Upon EMS arrival, initial rhythm was ventricular fibrillation. He was treated by CPR and electrical defibrillation and regained spontaneous circulation temporarily, but when he arrived to the emergency department he did not have any palpable central pulses. After arrival, patient continuously had the chest compressions, was ventilated via ETT, had 3 rounds of electrical defibrillation (all according to ACLS protocol). 2 minutes of CPR, he regained his pulses and went back to a normal sinus rhythm. PMH: Open heart surgery. Meds, allergies, FH: Unknown SH: lives with wife HPI: 78 yo M, brought to ED by ambulance in complete cardiac arrest. Patient was with his family out to dinner, and suddenly became unresponsive, fell from sitting position. Upon EMS arrival, initial rhythm was ventricular fibrillation. He was treated by CPR and electrical defibrillation and regained spontaneous circulation temporarily, but when he arrived to the emergency department he did not have any palpable central pulses. After arrival, patient continuously had the chest compressions, was ventilated via ETT, had 3 rounds of electrical defibrillation (all according to ACLS protocol). 2 minutes of CPR, he regained his pulses and went back to a normal sinus rhythm. PMH: Open heart surgery. Meds, allergies, FH: Unknown SH: lives with wife

Case

Pneumothorax Definition: separation of visceral and parietal pleurae by gas in the pleural space. secondary spontaneous pneumothorax (SSP) is complication of underlying lung disease. primary spontaneous pneumothorax no precipitating event (absence of clinical lung disease). Types: Simple (ex. Bleb) pleural pressure becomes slightly more positive than the pleural pressure in the contralateral hemithorax, but still remains subatmospheric. only modest repercussions unless the patient has limited respiratory reserve or is being mechanically ventilated. Tension (ex. Trauma) intrapleural pressure exceeds atmospheric pressure, particularly in expiration. "check valve" mechanism Open from a chest wall defect Definition: separation of visceral and parietal pleurae by gas in the pleural space. secondary spontaneous pneumothorax (SSP) is complication of underlying lung disease. primary spontaneous pneumothorax no precipitating event (absence of clinical lung disease). Types: Simple (ex. Bleb) pleural pressure becomes slightly more positive than the pleural pressure in the contralateral hemithorax, but still remains subatmospheric. only modest repercussions unless the patient has limited respiratory reserve or is being mechanically ventilated. Tension (ex. Trauma) intrapleural pressure exceeds atmospheric pressure, particularly in expiration. "check valve" mechanism Open from a chest wall defect

Pneumothorax Signs/symptoms: Sudden shortness of breath, dry coughs, cyanosis (turning blue) and pain felt in the chest, back and/or arms Consequences hypoxia -> loss of consciousness and coma shifting mediastinum away from injury -> obstruct SVC and IVC -> reduced cardiac preload and CO. Untreated, a severe pneumothorax can lead to death within several minutes. Tension: medical emergency (air accumulates with each breath) Non-tension: less severe pathology (no accumulation) Signs/symptoms: Sudden shortness of breath, dry coughs, cyanosis (turning blue) and pain felt in the chest, back and/or arms Consequences hypoxia -> loss of consciousness and coma shifting mediastinum away from injury -> obstruct SVC and IVC -> reduced cardiac preload and CO. Untreated, a severe pneumothorax can lead to death within several minutes. Tension: medical emergency (air accumulates with each breath) Non-tension: less severe pathology (no accumulation)

Radiographic Features white visceral pleural line no pulmonary vessels are visible beyond the visceral pleural edge. Deep sulcus sign Size (British Thoracic Society guidelines) Small: distance from chest wall to the visceral pleural line < 2 cm Large: >2cm Some clinicians prefer 3cm. Tension pneumo: shows distinct shift of the mediastinum to the contralateral side and flattening or inversion of the ipsilateral hemidiaphragm white visceral pleural line no pulmonary vessels are visible beyond the visceral pleural edge. Deep sulcus sign Size (British Thoracic Society guidelines) Small: distance from chest wall to the visceral pleural line < 2 cm Large: >2cm Some clinicians prefer 3cm. Tension pneumo: shows distinct shift of the mediastinum to the contralateral side and flattening or inversion of the ipsilateral hemidiaphragm

Treatment SSP: Observation, O2 (stable; <2cm) Chest tube (stable, >2cm) or (unstable pts) PSP: Observe with O2 (stable, <2cm); d/c 6hrs if repeat CXR excludes progression and patient has access to EMS pleural aspiration with needle (stable, >2cm) clinically stable with a recurrent PSP undergo VATS after chest tube insertion chest tube insertion: (unstable) SSP: Observation, O2 (stable; <2cm) Chest tube (stable, >2cm) or (unstable pts) PSP: Observe with O2 (stable, <2cm); d/c 6hrs if repeat CXR excludes progression and patient has access to EMS pleural aspiration with needle (stable, >2cm) clinically stable with a recurrent PSP undergo VATS after chest tube insertion chest tube insertion: (unstable)