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Surgery Exam > Thoracic/CV Emergencies > Flashcards

Thoracic/CV Emergencies Flashcards

1
Q

Penetrating Chest Trauma Organs

A

Heart, Lungs, Arteries/Veins, Pulmonary Hilum, Esophagus, Tracheobronchial Tree

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2
Q

Blood/fluid in pleural space

A

200-300mL to be visible on CXR

1500 “massive” hemothorax

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3
Q

Penetrating Chest Trauma S/Sx

A 
Hemoptysis
Pneumothorax
Subcutaneous Emphysema
Mediastinal Emphysema
Dullness/Absent Breath Sounds
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4
Q

Beck’s Triad

A

Low systolic/high diastolic (narrowed pulse pressure)
Muffled heart sounds
JVD

Cardiac tamponade

EKG in tamponade: low voltage QRS, electrical alternans

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5
Q

Penetrating Trauma Workup

A 
Helical CT
ECHO
Angiography
Esophogram
Bronchoscopy
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6
Q

Procedures in Penetrating Trauma

A

Right/Left thoracotomy, sternotomy, or clam-shell

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7
Q

Fractures in CT trauma

A 
Rib fractures (1st, 2nd - lot of force)
> 3 ribs (on same side)
Uncomplicated: tx pain and d/c, pain management, avoid PNA
Associated with significant intrathoracic/intra abdominal injuries: 
Multiple/displaced rib fx
Scapula
Flail chest
Sternal
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8
Q

Traumatic diaphragmatic hernia

A

1% admitted blunt trauma
Male > Female
Mostly left, some right, some bilateral

Marked distress, decreased breath sounds, bowel sounds in chest, abd pain, paradoxical respiration

Trans abdominal repair

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9
Q

Pulmonary contusion

A 
First 24 hours
Irregular, nonlobular obpacification of pulmonary parenchyma
Only some on CT
Can progress
Pain control, pulm support
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10
Q

PE findings associated with severe ct trauma

A 
Paradoxical chest movement
Hypoxia, respiratory distress
Seat belt sign
Palpable deformity of sternum/ribs
Abd tenderness/guarding
Hemoptysis 
Hemodynamic instability
Lung sounds changes: absent/decreased, unilateral, bowel sounds

JVD
Tracheal deviation

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11
Q

Hiatal hernia

A

Paraesophageal: bad

Sliding: eh

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12
Q

Esophageal procedures/tx

A

Anti-reflux: nissen fundoplication, other options

Achalasia: Nitrate/CCB; surgical: botox, endoscopic pneumatic dilatation, myotomy, esophagectomy

Perforation: HIGH LETHALITY IF MISSED
Most common cause: Iatrogenic
Cervical: instrument
Distal: spontaneous
Hamman’s sign: crunch, raspy sounds synched w/ hr
Acute pain in chest/neck/epigastric; dysphagia, fever, tachypnea, n/v; sub q emphysema, crepitus, seems septic
Large perf/mediatinitis, sepsis, shock –> emergent surgery
NGT maybe, NPO, IVF, Abx
Iatrogenic: medical management

Boerhaave: ETOH, violent vomiting, retching. 10% of perforations. left posterolateral distal. Fatal if not diagnosed
Always operate; still 25% mortality
Dx: CXR (free air), CT, Esophogram w/ gastrograffin

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13
Q

Hempotysis

A

MCC: bronchitis
PNA, TB, Ca, foreign body (peds), trauma, PE

Bacterial 70%

Dx: PPD, CBC, culture, CXR, CT, Angio

200 mL/day: massive
surg: bronchoscopy, angiography, resection

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14
Q

Spontaneous Pneumo:

A

Primary: no obv cause (thin tall young men)
Secondary: lung dz

rupture of bleb, secondary to emphysema, cf, tb, ca

less than 30%: O2
more than 30: chest tube

Recurrent: VATS

Tension: emergency; needle to decompress

Do not clamp chest tube

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15
Q

Aneurysm

A

1.5-2x normal
Cb atherosclerotic, rarely symptomatic
Almost always comorbidities

Thoracic aortic: cb emergency
S/Sx: Compression, pain, hoarseness, regurgitation
Ascending/arch: Sternotomy, may need valve
Descending: left thoractomy or endovascular

AAA rupture: abd pain, pulsatile abd mas, tenderness, hypotension
10 units blood
SBP goal 80-100
ER to OR ASAP (dacron graft, stents)
Cab endovascular if stable or not yet ruptured

Repair: potential complication of IMA ischemia

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16
Q

Aortic dissections - classifications and s/sx

A

Debakey:

1: both ascending/descending
2: Ascending
3: Descending

Stanford:
A: Ascending/both
B: Distal only

S/sx: Chest/back pain, HTN, neuro changes, distal ischemia, acute failure, varied BP/limbs

Hyptension, shock
High lethality

TRIAD:

1) Abrupt onset of pain (thoracic/abdominal) sharp/tearing
2) Mediastinal/aortic widening on CXR
3) HTN/discrepant BP

17
Q

Aortic dissections - workup, management

A 
Imaging: 
Spiral CT (gold), MRI, TEE (may miss distal tears, good for valve eval)

Medical management: Reduce systolic BP (below 100-120)
Decrease LV
B block first( esmolol) THEN vasodilators if necessary

Ascending: Emergent surgery always, high mortality
Complications: rupture, camponade, regurg, ischemia

Descending:
Uncomplicated (no rupture/ischemia): medical
Complicated/failed medical: surgical, endovascular

18
Q

Transection of thoracic aorta

A

Blunt chest trauma
Rapid deceleration
Complete: dead at scene, 15% of MVA daths

NOT stable but can look it

Intermittent response to fluid

“funny looking mediastinum”, blurred aortic knob, 2nd rib fx

CXR then spiral CT

Repair: can lead to paraplegia w/ artery of Adamkiewicz
Techniques: open vs endovascular
clamp and run vs bypass

19
Q

Myocardial contusion

A

MVA, falls, car/pds, baseball
Similar symptoms to MI: pain in chest, N/V, SOB
Arrhythmia, infarct, ructure

Often Right side of heart

If ok at 48 hours –> can d/c
Serial EKG, tele, enzymes
ECHO

20
Q

Management pericardial tamponade

A 
AVOID vasodilators (anesthetics, O2, fluids) 
DRAIN ASAP

Hx: trauma, surg, pericarditis, malignancy
Exam: anxious, inc RR/HR, dec heart sounds, JVD, orthostatic, hypotension
Widened mediastinum
Fluid on ECHO

21
Q

Acute MI Emergencies

A 
Acute VSD: 2-5 days post MI
Often transmural/anterolateral
New onset harsh holosystolic murmur, often with thrill
Worse hemodynamics
Dx with ECHO
Urgent surgical repaid

Acute mitral regurgitation
5% of mortality in acute MI
Mean time 13h onset, up to 5-7 days

Papillary rupture (more common with inferior MI; sometimes anteromedial)
Acute pulm edema, pansystolic murmur apex/axilla
Afterload reduction, often surgery

Dressler’s

22
Q

CABG

A

Coronary Arter Bypass Graft

1-2 days ICU, then step-down
3-6 day hospital stay
Extubated same day
Foley, chest tubes, Aline, Central line, maybe Swan-Ganz

Dopamine, Milrinone
Alpha agonist - counter vasodilation
NTG - spasm
ASA, anti-coag OR pro-coag, depending on bleeding

23
Q

CABG complications

A 
constipation
depression
poor appetite
leg swelling
infection

Bleeding, MI, low CO, arrhythmia, a-fib (up to 40%), SVT, stroke, changes in cognitive, pulmonary, infection, renal failure, pericarditis, pleural effusions, phrenic nerve damage

24
Q

Acute mesenteric ischemia - causes

A

Arterial embolism: 1/3 of cases (secondary to Afib, usually SMA)

Arterial thrombus: 1/3 cases
Progression of pre-existing atherosclerosis
Often 2 vessels
Precipitated by dehydration, hypercoagulable

Venous thrombus:
Hypercoagulable

Non-occlusive:
Severe/prolonged vasoconstriction
Shock / low CO
Iatrogenic alpha agonists, ergots, cocaine

25
Q

Acute mesenteric ischemia - diagnosis

A

< 12 hours important

Triad: GI emptying, abd pain, underlying cardiac dz
Limited PE findings
N/V, diarrhea, ileus

leukocytosis, d-dimer, lactate

CT / angiography

26
Q

Acute mesenteric ischemia - treatment

A

Papaverine infusion
Surgical embolectomy
Intrarterial thrombolysis
Bypass/reimplantation (esp thrombus)

Maybe 2nd look op

Venous thrombus: may be ok with just anti coag
Acute/subacute/chronic

27
Q

Aorto-Iliac Occlusive Dz

A

Acute - emergency
Saddle embolism or in situ thrombosis

Neuro deficits (inc paralysis)
Absent femoral pulses (differentiate from spinal cord)

Quick imagine, operate

blue toe syndrome: mini emboli, may herald more severe

28
Q

Compartment Syndrome

A 
Pallor
Pulselessness
Parasthesias
Paralysis
Poikilothermia
PAIN

Surgery Exam (4 decks)

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