Urgent pleural disorders Aleš Rozman University Clinic of Respiratory Diseases and Allergy, GOLNIK,...
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![Page 1: Urgent pleural disorders Aleš Rozman University Clinic of Respiratory Diseases and Allergy, GOLNIK, Slovenia Portorož – 8th May 2009.](https://reader037.fdocuments.in/reader037/viewer/2022103006/56649eeb5503460f94bfcf64/html5/thumbnails/1.jpg)
Urgent pleural disordersAleš Rozman
University Clinic of Respiratory Diseases and Allergy,
GOLNIK, Slovenia
Portorož – 8th May 2009
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Pleural emergencies:
• haemorrhage
- haemothorax
• elevated pleural pressure
- tension pneumothorax
- massive pleural effusion
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1. Haemothorax= pleural fluid with Ht > 50% blood Ht
CAUSES:• chest trauma: penetrating / non – penetrating
(lung blood vessels, chest wall, diaphragm, pleural adhesions, mediastinum, large vessels, abdomen)
• iatrogenic(pleural biopsy, subclavian or jugular CVC placement, thoracentesis, transthoracic or transbronchial NA, esophageal variceal TH,...)
• nonthraumatic(pleural malignancy, anticoagulant TH, spontaneous rupture of vessel (AO aneurism), bleeding disorder, thoracic endometriosis,...)
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1. Haemothorax
DG:
• CXR
• chest CT – for all patients with severe chest trauma
• thoracentesis
transudate
haemothorax with higher attenuation (> 35 HU)
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1. Haemothorax
TH:
• immediate tube thoracostomy1. evacuation of blood2. stop bleeding by apposition of pleural surfaces3. evaluation of blood loss4. may decrease incidence of empiema or fibrothorax5. autotransfusion possible
• thoracotomy (cca 15%)1. immediate drainage of > 20 ml/kg of blood2. persistent bleeding > 200 ml/h3. cardiac tamponade, vascular injury, pleural contamination,
major air leaks,...
•TH of shock, blood and fluid replacement,...
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1. Haemothorax
Complications:
1.retention of clotted blood (evacuation if > 30% of
hemiTHX)
2.empyema (3 – 5%)
– shock, contamination, prolongued drainage, abdominal injuries
3.exudative pleural effusion (15 – 30%)
4.fibrothorax (< 1%)
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2. Tension PTHX= air in the pleural space, which pressure exceeds the atmospheric pressure throughout expiration (inspiration).
CAUSES – any type of PTHX:
1. with mechanical ventilation / NIPPV
2. during cardiopulmonary resuscitation
3. in divers
4. in air travel
5. in spontaneously breathing person at constant pressures (airway,
environment)
6. improper chest tube handling
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Pneumoscrotum secondary to bilateral tension pneumothorax
Di Capua-Sacoto C, Bahilo-Mateu P, Ramírez-Backhaus M, Gimeno-Argente V, Pontones-Moreno JL, Jiménez-Cruz JF Servicio de Urología. Hospital Universitario La Fe. Valencia. Spain Actas Urol Esp. 2008;32(7):756-758 ABSTRACTPNEUMOSCROTUM SECONDARY TO BILATERAL TENSION PNEUMOTHORAXWe report a case of pneumoscrotum secondary to a large bilateral tension pneumothorax. Although pneumoscrotum is an infrequent clinical condition that is generally resolved by means of conservative management, it may be a symptom of a serious and potentially life-threatening process. The management of pneumoscrotum should be directed to resolve the underlying cause.Key words: Pneumoscrotum. Pneumothorax. Complications.
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2. Tension PTHX
Patophysiology:
• impaired venous return and decreased cardiac output
• V/Q mismatch - profound hypoxia
Clinical manifestations:
• sudden deterioration
• dyspnoe, cyanosis, tachicardia, profuse sweating
• hypotension, low O2 saturation, distended neck veins
• subcutaneous emphysema, unilateral hyperinflation
• respiratory acidosis, hypoxemia
• sudden increse in plateau and peak pressures (volume – type vent.)
• sudden drop of tidal volumes (pressure – type vent.)
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2. Tension PTHX
hyperinflation
collapsed lung
mediastinal shift
low hemidiaphragm
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TH:
• medical emergency – clinical diagnosis
• do not wait for CXR
• 100% O2
• observation, auscultation, percussion
• needle & syringe with saline – 2nd anterior ICS
• bubbles? – replace with large - bore needle
• prepare for tube thoracostomy
2. Tension PTHX
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3. Massive pleural effusion
CAUSES:
• malignant pleural effusion
PATOPHYSIOLOGY:
• impaired venous return and decreased cardiac output
• V/Q mismatch - profound hypoxia
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Clinical manifestations:
• gradual deterioration
• dyspnoe, cyanosis, tachicardia
• hypotension, low O2 saturation, distended neck veins
• unilateral distension of THX, absent respiratory mobility
3. Massive pleural effusion
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3. Massive pleural effusion
mediastinal shift
distension
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TH:
• thoracentesis for symptomatic relief (500 – 1000 ml)
• consider chest tube and pleurodesis
• avoid rapid evacuation of all pleural fluid (reexpansion
lung edema, PTHX)
3. Massive pleural effusion
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• Haemothorax and tension pneumothorax can be
iatrogenic.
• Careful monitoring of patients and early recognition of
complications should be a standard after each invasive
procedure.
3. Conclusions
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Thank you.University Clinic Golnik,
Slovenia