Fwd: Cardiothoracic surgery Bambury

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From: UCD Graduate '09 None <ucdgrad09@gmail.com&gt;
Date: 2009/2/25
Subject: Cardiothoracic surgery Bambury
To: ucdgrad09@gmail.com

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  • 1. Cardiothoracic Surgery Pneumothorax
  • 2. CLASSIFICATION
    • Primary spontaneous
    • Secondary spontaneous
    • Traumatic
    • Tension
    • Definition- injury to the lung resulting in release of air into the intrapleural space(between the parietal and visceral pleura)
  • 3. Primary spontaneous
    • Tall thin people
    • Age; 20-30 years old
    • Smokers- occurrence increases directly with the number of cigarettes smoked per day
    • Familial
    • Presentation
      • Sudden onset SOB
      • Associated with chest pain
  • 4. Secondary spontaneous
    • Underlying pulmonary pathology
    • Most commonly seen in COPD patients
    • Other causes include
      • Sarcoidosis
      • Tuberculosis
      • Cystic fibrosis
      • Malignancy
      • Idiopathic pulmonary fibrosis
  • 5. Traumatic pneumothorax
    • Penetrating versus blunt chest trauma
  • 6. Tension pneumothorax
    • Surgical emergency
    • Definition-a build up of positive pressure within the hemithorax-mediastinal shift.
    • One way valve mechanism- air enters alveoli but can’t escape as the lung tissue collapses around the hole in the pleura.
  • 7. Examination
    • Decreased or absent breath sounds on affected side
    • Hyperresonance
    • Decreased tactile fremitus
    • Hypotension
    • Tachycardia>130
    • Tachypnoea
    • Cyanosis
    • Distended jugular venous pulsation
    • Tracheal deviation to contralateral side
  • 8. Mediastinal shift
    • Pressure on unaffected lung interferes with gas exchange leading to hypoxaemia
    • Pressure on the heart reduces venous return to the heart reducing cardiac output.
    • Leads to cardiorespiratory failure
  • 9. Investigations
    • Chest X ray- should never be performed when suspecting tension pneumothorax
    • ABG-hypoxaemia
    • Imaging to distinguish Bullae at apex from pnemothotax- in emergency setting U/S or CT if not an emergency
  • 10. Management of spontaneous pneumothorax
    • Observation with follow up X-ray
    • Tube thoracostomy
  • 11. Management of tension pneumothorax
    • Immediately insert a large bore cannula into 2nd intercostal space in midclavicular line
    • Hissing sound will be heard
    • Follow by inserting a chest drain
  • 12. Insertion of chest drain
    • NB remember surgical principles ie aseptic technique
      • Paint with Bethadine
      • Drape the surrounding area
      • Triangle of safety is
        • 1) anterior to the midaxillary line
        • 2) above the level of the nipple
        • 3)below and lateral to the pec major
      • 5th intercostal space in midaxillary line
  • 13. Insertion of chest drain
    • Sharp dissection of skin
    • Blunt dissection through the remaining tissue as far as the parietal pleura
    • The tract should be just above the lower rib to avoid the neurovascular bundle aiming toward the apex.
    • Insert finger into cavity and use this to guide the trocar
  • 14. Insertion of chest drain
    • Remove the trocar and the tube is carefully and securely positioned using a purse string suture.
    • Tube is then connected to an underwater seal and bubbling of the water is observed.
    • Request a chest x ray to determine correct positioning of the tube and reinflation of the lung
  • 15. Definitive surgical management
    • Indications
      • Recurrent pneumothorax for any reason
      • Patients with
      • high risk occupations eg pilots, divers.
  • 16. Definitive surgical management
    • Surgical options
      • Pleurodesis- tube thoracostomy with preferred agent being talc
      • Thorocotomy with pleurectomy
      • VATS- video assisted thorascopic surgical biopsy with talc insufflation
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  • 24. Classification
    • Primary spontaneous
    • Secondary spontaneous
    • Traumatic
    • Tension