Emergency Medicine No nancial Topics disclosures David Duong, MD - PowerPoint PPT Presentation

UCSF Family Medicine Board Review Course Emergency Medicine No Þnancial Topics disclosures David Duong, MD MS UCSF-SFGH Emergency Medicine Residency Tuesday, March 17, 15 Tuesday, March 17, 15 Case #1 Case #1 ¥ 20-yo M with no PMHx presenting with non-radiating, pleuritic right 20-yo M with CP ¥ Exam is unremarkable except that sided chest pain starting about 5 the patient is tachycardic and with hours ago while playing video games. decreased breath sounds on right. transient sensation of palpitations. no dyspnea. no leg swelling, denies ¥ Pt is speaking comfortably, chest trauma. wall non-tender ¥ CXR is obtained ¥ occasional TOB, remainder of history unremarkable Tuesday, March 17, 15 Tuesday, March 17, 15

Case 1, Q #1 ¥ Which of the following conditions is most likely to be a precipitating factor for pneumothorax? a) COPD b) cigarette smoking c) marfan syndrome d) exertion e) Pneumocystis pneumonia Tuesday, March 17, 15 Tuesday, March 17, 15 Case 1, Q #1 Pneumothorax ¥ Which of the following conditions is most likely to be a precipitating factor for ¥ Primary Spontaneous - occurring in pneumothorax? patients without underlying lung dz a) COPD ¥ account for 2/3 of all PTX b) cigarette smoking ¥ more common in tall, thin men, c) marfan syndrome 20-40 years of age and SMOKERS d) exertion ¥ 20:1 increased risk in smokers e) Pneumocystis pneumonia Tuesday, March 17, 15 Tuesday, March 17, 15

Other choices Pneumothorax ¥ Marfans is a risk factor in primary spontaneous PTX, but is not as strong ¥ Secondary Spontaneous - occurring in a risk factor patients with existing underlying lung ¥ Exertion is not a risk factor disease (COPD, PCP) ¥ COPD and PCP pneumonia are ¥ PCP is the most common cause of important risk factors for secondary pneumothorax in HIV patients PTX, but are not as common as primary PTX Tuesday, March 17, 15 Tuesday, March 17, 15 Traumatic Case 1, Q #2 Pneumothorax ¥ The nurse reports that this patient has become very ¥ More common in penetrating trauma dyspneic and his blood pressure is now 80/50. His neck veins are distended. What is the next best (stab wound, gun shot wound) than blunt course of action? trauma (rib fractures) a) 100% oxygen via non-rebreather ¥ Includes iatrogenic PTX b) immediate placement of a chest tube ¥ Transthoracic needle procedures c) intubation (thoracentesis, needle biopsies) d) needle thoracostomy ¥ Subclavian central lines e) normal saline 1000 cc IV bolus Tuesday, March 17, 15 Tuesday, March 17, 15

Case 1, Q #2 Tension Pneumothorax ¥ Positive pressure from PTX reduces ¥ The nurse reports that this patient has become very dyspneic and his blood pressure is now 80/50. His venous return to the right heart, thus us return to the right hear neck veins are distended. What is the next best decreasing cardiac output easing cardiac output course of action? ¥ PE: distended neck veins, tracheal distended neck veins, trach a) 100% oxygen via non-rebreather deviation (away from side of PTX), ation (away from side of PT b) immediate placement of a chest tube hypotension otension c) intubation ¥ Immediate decompression required: 14 ediate decompression requ d) needle thoracostomy gauge needle - 2nd intercostal space, e needle - 2nd intercostal s mid-clavicular line e) normal saline 1000 cc IV bolus Tuesday, March 17, 15 Tuesday, March 17, 15 Pneumothorax and Pneumothorax and Treatment Treatment ¥ High-Flow oxygen: ¥ Needle thoracostomy: ¥ promotes resorption of nitrogen-rich air in PTX ¥ indicated in tension pneumothorax ¥ appropriate as sole therapy in small (<15%), stable, ¥ insert 14 gauge IV in 2nd intercostal space, and atraumatic PTX mid-clavicular line ¥ Observation: ¥ Tube Thoracostomy: ¥ for small, primary spontaneous PTX ¥ for larger (>15%) spontaneous PTX and all traumatic PTX ¥ repeat CXR in 6 hours - if no change on CXR and clinically, follow-up is ensured, and reassuring social ¥ chest tube is placed at 4th or 5th intercostal situation -> may be discharged with another repeat space, mid-or anterior-axillary line CXR recommended in 12-48 hours. Tuesday, March 17, 15 Tuesday, March 17, 15