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SYB
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
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
Pneumothorax

Signs/symptoms:


Sudden shortness of breath, dry coughs, cyanosis
(turning blue) and pain felt in the chest, back and/or
arms
Consequences



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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



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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:



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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)