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Utah / kirklin > Thoracic 2.0 (with infection) > Flashcards

Thoracic 2.0 (with infection) Flashcards

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1
Q

Anatomy

Complete course of the Right Vagus Nerve

A
  1. Origin:
    1. nucleus ambiguus,
    2. dorsal motor nucleus,
  2. Exits the base of the skull via the jugular foramen
    1. Descent in the Neck:
    2. lateral to the carotid artery. ,
    3. Remains in carotid sheath through to the thoracic inlet
  3. At the origin of the carotid artery:
    1. the nerve crosses lateral to the bifurcation of the brachiocephalic artery
    2. descends over the anterolateral part of the main stem trachea,
    3. proceeding under the arching part of vena azygos
  4. infra-azygos course:
    1. it lies superficial to the esophagus
    2. between the ascending part of the azygos vein and bronchus intermedius.
    3. then behind the hilum of the lung.
  5. the lower third of the esophagus,
    1. it breaks up and mingles with branches from the left vagus nerve to form the anterior and posterior esophageal vagal plexuses.
  6. Throughout its course in the chest, the vagus nerve remains covered by the mediastinal pleura.
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2
Q

Anatomy- Right vagus nerve:

what are its origins?

where does it exet the skull ?

path in which it descends in the neck?

A
  1. Origin:
    1. nucleus ambiguus,
    2. dorsal motor nucleus,
  2. Exits the base of the skull via the jugular foramen
    1. Descent in the Neck:
    2. lateral to the carotid artery. ,
    3. Remains in carotid sheath through to the thoracic inlet
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3
Q

Anatomy - Right vagus nerve

What is the behavior of the thoracic nerve once it enters the thoracic inlet ?

A
  1. crosses lateral to the bifurcation of the brachiocephalic artery
  2. descends over the anterolateral part of the main stem trachea,
  3. under the arching part of vena azygos:
  • it lies superficial to the esophagus
  • between the ascending part of the azygos vein and bronchus intermedius.
  • then behind the hilum of the lung
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4
Q

Anatomy -

Course of the right recurrent laryngeal nerve

A
  • separates off the vagus nerve at a variable point
  • remains within its sheath (two bananas in one skin).
  • descends parallel to the vagus nerve
  • origin of the right common carotid and subclavian arteries
    • (the terminal divisions of the brachiocephalic artery.)
  • “looping around the distal bifurcation of the brachiocephalic artery”.
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5
Q

Non-recurring RLN

  • prevlance
  • settings in which it is described
A

Non-recurring RLN

  • In 0.5% - 1% of population,
  • described
    1. right-sided aortic arch
    2. retropharyngeal left subclavian artery
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6
Q

What is the impact of a rib fracture on the mortality of a of an elderly trauma patient?

A

65 year old or older are 5x more likely to die from that injury.

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7
Q

Trauma

ECG findings of cardiac contusion vs MI/Thrombus

A
  • ST elevation more associated with MI
  • Non-specific flattening or T wave inversion
    • is more commonly contusion
  • Ventricular arrhythmia are always concerning
  • EKG evidence of Frank MI – need to think about coronary injury – or thombus
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8
Q

Trauma

ECG changes that are criteria for admission?

A
  • New arrhythmia
  • ST segment / ischemic changes
  • Heart block
  • Otherwise unexplained sinus tachycardia
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9
Q

alpha -1 AT Disease

Increase in the risk of pulmonary disease ?

A

in the setting of enzyme deficiency – the risk of pulmonary disease is 20-30x times that of the geneal population

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10
Q

alpha -1 AT Disease

Prevelance in the U.S.?

A

40,000 people of the US

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11
Q

alpha -1 AT Disease

% of the population with emphysema ?

A

1-2% of those with emphysema

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12
Q

Proximal acinar emphysema (Centrilobar )

  • Associated with what disease states ?
A

Proximal acinar emphysema (Centrilobar )

  • Associated with:
    1. Smoking
    2. Inflammation of the distal airways
      *
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13
Q

Proximal acinar emphysema (Centrilobar )

  • is typically located in what parts of the lungs?
A

Proximal acinar emphysema (Centrilobar )

  • Location:
    1. Upper airways
    2. uneven distribution
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14
Q

Panacinar emphysema (panlobular)

A

Panacinar emphysema (panlobular)

  1. Involves the acinus uniformly
  2. Alpha-AT D and PI inhibitor emphysema

Lower lung zones

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15
Q

Interstitial lung disease associated with ptx

A

Interstitial Disease Related to Pneumothorax

  1. Idiopathic pulmonary fibrosis
  2. Eosinophilic pneumonia
  3. Sarcoidosis
  4. Tuberous sclerosis
  5. Lymphangioleiomyomatosis (LAM)
  6. Collagen vascular disease
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16
Q

what side are Catmenial Ptx typically on ?

A

90% are on the right

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17
Q

Ptx associated with AIDS / PCP pneumonia

Hospital mortality ?

A

Overall 50%

Approaches 90% on a ventilator

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18
Q

PTx with AIDS and PCP pneumonia

overall survival

A

months

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19
Q

PTx associated with HIV/PCP

treatment

A

Chemical pleurodesis is ineffective

VATS is preferable

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20
Q

Hemothorax - spontaneous

causes

A
  • Benign
    • Spontaneous ptx
    • Pulmonary AVM
  • Malignant
    • Metastatic melanoma
    • trophoblastic tumor
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21
Q

Spontaneous Hemothorax

Most common malignant causes ?

A

Malignant

  • Metastatic melanoma
  • trophoblastic tumor
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22
Q

size of ptx that is OK to observe

A

if its is < 20%

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23
Q

Signs of a Pneumothorax in the ICU (2)

(i.e. the ventilated patient) ?

A

Signs:

  1. Increasing PaCO2
  2. Decreasing compliance
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24
Q

Pneumothorax in the ICU

what % of ventilated patients devellop a Ptx?

A

Pneumothorax in the ICU

Approximately 1% of all ventilated patients

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25
_Pneumothorax in the ICU_ At what size of ptx can a Ptx become audible?
Breath sounds are audible until a PTx \> 50%
26
Cardiac causes of acute pulmonary edema
1. Failure of mitral repair 2. paraprosthetic leaks 3. conduit occlusition 4. cardiac tamponade
27
Lifetime risk of ptx in smoking male vs non smoking male
Smoking male: 12% Non smoking male: 0.1%
28
Exudate - specific gravity
\> 1.02
29
Exudate protein concentration
\> 2.0g/dl
30
Light's Criteria
To determine an **exudate**: 1. Specific gravity \> 1.02 2. Protein \> 2.0g/dl *at least one of :* 1. protein: pleural/serum \> 0.5 2. LDH: pleural / serum \> 0.6 3. LDH: total LDH \> 2/3\* ULN
31
**_Lung Abscess_: *Medical Treatment*** Duration for initial treatment with antibiotics?
**_Lung Abscess_: *Medical Treatment*** Rx: 6-8 weeks of appropriate antibiotics
32
**_Lung Abscess:_ Medical Treatment** % of time medical treatment is effective
_Result:_ 90% patients respond to targeted antibiotic therapy alone *and* do not require surgical intervention
33
Six Indications for surgery for a lung abscess
Indications for surgery 1. *Failed* _medical_ therapy 2. *Persistent* e_ndobronchial obstruction_ 3. Formation of an _empyema_ 4. _Hemorrhage_ 5. BP _fistula_ 6. Inability to *rule out* _malignancy_
34
**_Hydatid Pulmonary Disease_** _Caused_ by ?
**_Hydatid Pulmonary Disease_** _Caused_ by *Echinococcus*
35
**_Hydatid Pulmonary Disease_** Presentation:
1. Cough 2. dyspnea 3. hemotypsis 4. Expectoration of cyst material 5. Acute pleural drainage may cause anaphylactic shock
36
**_Pulmonary Hydatid Disease:_** Issue with drainage of cyst:
Acute pleural drainage may cause anaphylactic shock
37
Casoni Skin test
* For Hydatid ( Echinococcus skin disease) * **immediate hypersensitivity** skin test * intradermal injection of 0.25 hydatid cysts/human cyst * Observations made for next 30 mins and after 1 to 2 days
38
Surgical treatment of Hydatid lung disease
* Avoid spilage * Cystectom +/- Anatomic resection * May need concurrent liver resection * Concurrent liver surgery
39
Diagnosis of Echinococcus lung infection
Diagnosis: * Serology (IgM / IgG hemagglutinatioin) * Casoni skin test
40
**_Pulmonary Amebiasis_** Pathophysiolgy
**_Pulmonary Amebiasis_** * _Causative organism & Pathophysiology:_ * *Entamoeba histolytica* * Transmitted via the fecal – oral route * Liver abscess à ruptures and extends into the surrounding tissues
41
**_Pulmonary Amebiasis_** Typical presentation
1. Right side chest pain --\> radiates to the shoulder 2. Cough * Initially brown and unproductive à becomes purulent chocolate brown sputum 3. Fever 4. Malaise 5. Anorexia 6. Weight loss 7. Dyspnea
42
**_Pulmonary Amebiasis_** Cough typical of the infection ?
_Cough_: * Initially brown and unproductive * becomes purulent chocolate brown sputum
43
**_Pulmonary Amebiasis_** Diagnosis:
Parasites found in the sputum (Sputum culture)
44
**_Pulmonary Amebiasis_** Treatment?
1. Metronidazole 2. Drainage of pleural fluid
45
**_Pulmonary actinomycosis_** * Organism ?
Pulmonary actinomycosis * Gram + organism
46
**_Pulmonary actinomycosis_** Presentation?
* 1. Chest pain 2. Dyspnea 3. Hemotypsis 4. Cough 5. Fever 6. Weight loss 7. Invasion of the chest wall with drainage
47
* **_Pulmonary actinomycosis_** * _Rx_:
* **_Pulmonary actinomycosis_** * _Rx_: * PCN for 5 weeks * Drainage of the plural fluid
48
Characteristic histology of Actinomycosis
Sulfur granules
49
What bacteria infections are most commonly related to lung abscesses in hospitalized patients ?
1. Staph 2. *Pseudomonas* 3. *Proteus* 4. *E. coli* 5. *Klebsiella*
50
Mycobacterium TB: _Typical anatomic location:_
_Typical anatomic location:_ Segmental pneumonia in: the apical or a superior segment of a lower lobe _Laterality_: Bilateral involvement is rather common
51
Mycobacterium TB Indications for surgery
1. Massive or Recurrent hemoptysis 1. \>600 cc/24 hrs (massive), severe \> 200cc/24 hours 2. bronchopleural fistula 3. bronchial stenosis 4. entrapped parenchyma 5. failure of medical treatment: 1. persistent positive cultures with cavitation after 5-6 months of optimal medical therapy with 2 or more drugs 6. Localized disease with MAI or other atypical myco or MDR 7. persistent cavitary disease 8. destroyed lung or lobe 9. to rule out malignancy.
52
Mycobacterium TB what is massive / severe hemotypsis
massive: \>600 cc/24 hrs severe: \> 200cc/24 hours
53
Mycobacterium TB: what is failure of medical treatment?
persistent positive cultures with cavitation after 5-6 months of optimal medical therapy with 2 or more drugs
54
_Mycobacterium TB -_ ## Footnote *Appropriate medical therpay*
_First-line therapy for MTB:_ * 6 months of _isoniazid_ and _rifampin_ * with the addition of _pyrazinamide_ and _ethambutol_ for the *initial 2 months*
55
_Extreme multi drug resistant TB:_
* resistance to both *isoniazid* and *rifampin* * Above + resistance to aminoglycosides or capreomycin
56
MTB pericardial effusion: Best way to make the diagnosis?
_Pericardial biopsy_ is used to make the diagnosis High levels of _adenosine deaminase_ activity in the pericardial fluid are indicative of MTB.
57
What protein is elevated in pericardial fluid associted with MTB ?
adenosine deaminase
58
Most common cause of severe hemotypsis * what % of cases ? * what % require surgery ? * how do most people die?
* TB is the most common cause of Severe Hemotypsis * TB accounts for 85% of the cases, but only 2% will require surgery * MCC of death with severe hemotypsis – is asphyxiation (not hypovolemia)
59
* _Rasmussen aneurysm_:
* Seen in the cavity of TB patiens * 4% of patients * pulmonary artery or arteriole in or near a TB cavity * May rupture, causing massive hemoptysis and asphyxiatio
60
Surgery for TB - what is the operative mortality
3-5%
61
Surgery for TB % frequency of successful clearance?
~95%
62
**_Histoplasmaosis_** Typical Environment?
Environment: Soil with chicken, pigeon,and bat feces
63
**_Lung mycotic infection_** Environment: Soil with chicken, pigeon,and bat feces
Histoplasmaosis
64
**_Histoplasmaosis_** Endemic area?
**Histoplasmaosis** _Endemic area:_ 1. Ohio and Mississippi rivers valley 2. Michigan 3. Ohio 4. Indiana
65
Lung mycoplasma infection Ohio and Mississippi rivers valley Michigan Ohio Indiana
Histoplasmosis
66
Sequale of Histoplasmosis
1. Granulomas: 2. Histoplasmomas 3. coin-lesions 4. Fibrosing mediastinitis 5. Broncholith 6. Traction diverticulum of the esophagus 7. Most common benign etiology of SVC obstruction 8. Chronic cavitary histoplasmosis
67
Most common benign cause of SVC syndrome
Histoplasmosis
68
Histology of Histoplasmosis
Budding yeast
69
Diagnosis
Histoplasmosis - budding yeast
70
_Coccidiomycosis_ Geographic distribution
* Mexico * Central America * Southwest United States
71
Pulmonary fungal infection with Geographic distribution: * Mexico * Central America * Southwest United States
Coccidiomycosis
72
Skin manifestation of Coccidiomycosis
Erythema nodosum - demonstrates a CMI
73
Syndrome associated with Coccidiomycosis
Valley Fever 1. Pneumonitis 2. Arthralgia 3. Typically self-resolved in the immunocompetent host. 4. _Erythema nodosum_ remains a positive prognostic sign of cell-mediated immunity.
74
Valley Fever
Due to pulmonary Coccidomycosis Pneumonitis Arthralgia Typically self-resolved in the immunocompetent host. Erythema nodosum remains a positive prognostic sign of cell-mediated immunity.
75
Coccidiomycosis - diagnosis
1. serology (IgM or IgG antiboidies) 2. culture.
76
Long term complications of coccidioimycosis
1. Chronic infection may result in cavitation of lung or formation of granulomatous nodules. 2. cavities are often located peripherally and may rupture into the pleural spacenwhich results in 1. effusion 2. pneumothorax 3. empyema 4. bronchopleural fistula. 3. Peripheral complications: * CNS infection
77
Treatment of "Valley Fever"
Tx for Coccidiomycosis * _Tx_: * Typically self limited * _Rx:_ * Amphotericin B for severe disease * Fluconazole or itraconazole for 3-6 months * _Surgical intervention:_ 1. Failure of medical management 2. Persistent cavitary lesion 3. Hemotypsis 4. Secondary infection 5. BPF 6. Persistent cavitary lesion Differentiate Coccidioides nodules from cancer.
78
Medical therapy for valey fever infection
* Coccidiomycosis * _Tx_: * Typically self limited * _Rx:_ * _Amphotericin B_ for severe disease * _Fluconazole_ or _itraconazole_ for 3-6 months *
79
Indicaiton for Surgical therapy for _coccidomycosis_
1. Failure of medical management 2. Persistent cavitary lesion 3. Hemotypsis 4. Secondary infection 5. BPF 6. Persistent cavitary lesion 7. Differentiate Coccidioides nodules from cancer
80
Coddiomycosis - histology
* Spherule containing endospore
81
Lung fungal infection * Spherule containing endospore
Coccidiomycois
82
Diagnosis ?
* Spherule containing endospore * Coccidoiomycosis
83
Blastomycosis - Endemic region
1. **_Endemic Region:_** 1. southeastern and central United States,
84
pulmonary fungus endemic to South East Unitited states
Blastomycosis 1. **_Causative agent:_** Blastomyces dermatidis 2. **_Endemic Region:_** 1. southeastern and central United States, 3. **_Tropism_**: 1. in the soil and inhaled to cause disease. 4. **_Manifestation of Blastomycosis_**: 1. pulmonary blastomycosis 1. flu like symptoms 2. non-productive cough 3. Acute pneumonitis 4. ARDS 5. Chronic pyogranulomatous lung disease 2. cutaneous blastomycosis 1. multiple ulcerated skin nodules in disseminated cases) 3. Disseminated blastomycosis
85
Manifestations of blastomycosis
1. pulmonary blastomycosis 2. cutaneous blastomycosis 3. Disseminated blastomycosis
86
Pulmonary blastomycosis
1. flu like symptoms 2. non-productive cough 3. Acute pneumonitis 4. ARDS 5. Chronic pyogranulomatous lung disease
87
Cutaneous blastomycosis
1. multiple ulcerated skin nodules in disseminated cases
88
Diagnosis
Cutaneous Blastomycosis
89
Broad based budding yeast
Blastomycosis
90
Diagnosis
Broad based budding yeast - blastomycosis
91
Thymus Arterial suppy Veinous drainage Lymphatic Drainage
_Blood supply:_ 1. IMA _Venous drainage:_ 1. Innominate vein 2. Internal thoracic veins _Lymphatic:_ 1. Lower cervical 2. Internal mammary 3. Anterior mediastinum 4. Hilar lymph nodes
92
Thymus - arterial blood supply
IMA
93
Thymus - venous drainage
Venous drainage: * Innominate vein * Internal thoracic veins
94
Thymus - lymphatic Drainge
_Lymphatic_: * Lower cervical * Internal mammary * Anterior mediastinum * Hilar lymph nodes
95
Most common anterior mediastinal mass
Thymoma
96
% of patients with thymoma that have MG
30% of patients with thymoma have MG
97
% of patients with Myastheisa Gravis that have Thymoma
10-20% of patients with MG have thymoma
98
Association of thymic cancer and MG
MG is rare in patients with thymic carcinoma
99
Syndromes related to thymoma
1. myasthenia gravis 2. RBC Hypoplasia 3. Hypogammaglobinemia 4. SLE 5. rheumatoid arthritis 6. ulcerative colitis 7. thyroiditis 8. Endocrine Paraneoplastic syndromes: 9. Addisons disease, Hyperparathyroid, panhypopitutiarism
100
Syndromes that are associated with thymoma that have a particularly poor prognosis
1. RBC Hypoplasia 2. Hypogammaglobinemia

Utah / kirklin (12 decks)

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