Pneumothorax..make the Diagnosis

Know the sulcus sign and make the pneumothorax Diagnosis...

Pneumothorax is frequently difficult to diagnose in the operating room or PACU . Sometimes it is obvious, with a hypoxic patient and absent breath sounds. But not usually. Most of the time we rely on a chest xray to help make the diagnosis.

Unfortunately, the good old chest xray only shows a pneumothorax about 30-50% of the time. A big part of the problem is that our patients are usually supine.A small pneumothorax make float anteriorly in the supine position, and if it is not big enough to wrap around the lateral edge of the lung, it may remain invisible. So you need to look for gross and subtle signs on the image that will help make the diagnosis. The deep sulcus sign is one of the more subtle signs.

Simply stated, the deep sulcus sign is a radiolucent (dark) lateral sulcus where the chest wall meets the diaphragm. The amount of lung in this area is less, so a small amount of air will tend to darken the area making it more prominent. Look at patient left in the left photo, and compare to their right side. It is much darker and appears to extend lower than usual. In more extreme cases, the amount of air just above the diaphragm may make it appear inverted (right photo).

Bottom line: If you see a deep sulcus sign on the chest xray image, strongly consider pneumothorax. If the patient begins to have hemodynamic problems, needle the chest and chase with a chest tube. If they remain stable, the patient will still require a chest tube. Chest xray always underestimates the true size of the pneumothorax. Place the usual size chest tube and manage per your usual protocol.

Comments

The pressure volume loop...

In the pressure-volume loop below, cardiac work is best represented by: the area of the curve the slope of the line from points C to D the distance of the line from points C to D the slope of a line from points A to D .. .. ... .... ... .... .... .... In the pressure-volume loop below, cardiac work is best represented by: the area of the curve Cardiac work is the product of pressure and volume and is linearly related to myocardial oxygen consumption. Cardiac work is best represented by the area of the curve of a pressure-volume loop.

Anaphylaxis updates part 2- Empty Ventricle Syndrome

Patients with anaphylaxis should not suddenly sit, stand, or be placed in the upright position. Instead, they should be placed on the back with their lower extremities elevated or, if they are experiencing respiratory distress or vomiting, they should be placed in a position of comfort with their lower extremities elevated. This accomplishes 2 therapeutic goals: 1) preservation of fluid in the circulation (the central vascular compartment), an important step in managing distributive shock; and 2) prevention of the empty vena cava/empty ventricle syndrome, which can occur within seconds when patients with anaphylaxis suddenly assume or are placed in an upright position. Patients with this syndrome are at high risk for sudden death. They are unlikely to respond to epinephrine regardless of route of administration, because it does not reach the heart and therefore cannot be circulated throughout the body

Steroids In Perioperative period...The Multi-purpose Drugs

1-Steroids are not Bronchodilator ,but have well established usefulness in hyper-reactive airway. They are also said to have a permissive role for bronchodilator medication. They can be administered orally, parenterally or in aerosol form 2- Steroids have been commonly used in chemotherapy for prevention of nausea along with other anti-emetic agents . Dexamethasone was found to be highly effective when given immediately before induction rather than at the end of anesthesia . 3- Steroids do exert analgesic effects. Various routes of administration of steroids include parentral, local infiltration at operated site , as an adjuvant in nerve blocks and central-neuraxial blockade. 4 - Steroids cannot be the mainstay of therapy in anaphylaxis because of the delayed onset of action, so they are used as adjunct after initial treatment with epinephrine. 5- Steroids (Dexamethsone) are of value in reduction or prevention of cerebral edema associated with parasitic infections and neopla...

sedationstation

Search This Blog