SYB

1
SYB

• Marni Scheiner
• MS IV

2
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

3
Case
4
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

5
Pneumothorax

• Signs/symptoms
• Sudden shortness of breath, dry coughs, cyanosis
  (turning blue) and pain felt in the chest, back
  and/or arms
• Consequences
• hypoxia -gt loss of consciousness and coma
• shifting mediastinum away from injury -gt obstruct
  SVC and IVC -gt 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)

6
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 lt 2 cm
• Large gt2cm
• Some clinicians prefer 3cm.
• Tension pneumo shows distinct shift of the
  mediastinum to the contralateral side and
  flattening or inversion of the ipsilateral
  hemidiaphragm

7
Treatment

• SSP
• Observation, O2 (stable lt2cm)
• Chest tube (stable, gt2cm) or (unstable pts)
• PSP
• Observe with O2 (stable, lt2cm) d/c 6hrs if
  repeat CXR excludes progression and patient has
  access to EMS
• pleural aspiration with needle (stable, gt2cm)
• clinically stable with a recurrent PSP undergo
  VATS after chest tube insertion
• chest tube insertion (unstable)