Surgery

1. SURGERY I : CHEST CONDITION.
GROUP 4-DCM MARCH 2023
ASSIGNMENT
1 ABUBAKAR
2 FAHAD ISMAIL
3 MISHI SOZA
4 YUSSUF BILE
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2. CONTENT TO BE COVERED
1 PNEUMOTHORAX
2 HAEMOTHORAX
3 EMPYEMA THORACIC
4 SURGICAL EMPHYSEMA
5 CARDIAC TAMPONADE
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3. objectives
 Definition
 Epidemiology/Incidence
 Pathophysiology
 Classification
 Risk factors/Causes
 Clinical presentation
 Investigation
 Management
 Complication
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4. 1 PNEUMOTHORAX
DEFINITION
 A pneumothorax is the presence of air or gas within the
pleural cavity i.e. the potential spaces between the
visceral pleural & parietal pleural of the lungs.
 This is usually from the defect on the lung surface e.g.
rapture bullae(Large blister ) or through the damage of
the chest wall e.g. following trauma.
 Air within the pleural cavity causes the physiological
pleural seal to be lost ,meaning the normal negative
pressure in this space , that aid the lung expanding within
the chest wall movement is lost.
 This impedes(prevent) lung expansion & leads to partial
or total lung collapse.
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5. Cont..
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6. 5/29/2023
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7. EPIDEMIOLOGY/INCIDENCE
 Annual incidence of pneumothorax is around 9% per
100,000
 Primary pneumothoraces occur most commonly in tall thin
men aged between 20-40
 They are less common in women- consider the possibility of
underlying lung disease e.g. LAM, Catamental
pneumothorax
 Cigarette or cannabis smoking is a major risk factor for
pneumothorax increasing the risk by factor of 22 in men &
9 in women
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8. Cont..
 The mechanism is unclear ; a smoking induced influx of
inflammatory cells may both break down elastic lung fibers
(causing bulla formation ) & cause small airway obstruction
(increasing alveolar pressure & the likelihood of interstitial
air leak)
 More common in patient with Marfans syndrome &
homocystinuria
 May rarely be farmilial
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9. PATHOPHYSIOLOGY
 As air enters the pleural space which normally have a
negative pressure , the elastic recoil in the lung tissue
causing either a partial or full lung collapse.
NORMAL PHYSIOLOGY
 Pleural space has a negative pressure
 Chest wall expand ►surface tension between parietal &
visceral pleural expands the lungs.
 Lung tissue has an elastic recoil► innate tendency to
collapse inward.
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10. Traumatic pneumothorax
 Closed pneumothorax : blunt trauma →lung damage →air
flow from the lung into the pleural spaces.
 Open pneumothorax : penetrating trauma to the chest
wall→ pathway for air directly into pleural spaces.
 Close & open pneumothorax : In closed pneumothorax air
travel in & out of the pleural spaces from the lungs .
 However in an open pneumothorax a defect in the chest
wall allows air to move in & out of the pleural spaces.
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11. Cont..
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12. Iatrogenic pneumothorax
 Induced in a patient by the treatment or comment of a
physician
 Lung surgery
 Central venous catheter insertion
 Thoracentesis -removal of fluid around the lung
 Mechanical ventilation
 Esophageal procedure
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13. Spontaneous pneumothorax
 Ruptured bleb→ air flow from the lungs into the pleural
spaces→ positive pleural pressure→ compressed lung.
 Lung collapse until an equilibrium is achieved or the rupture
seals
 Vital capacity & ↓ partial pressure of oxygen
 Primary/idiopathic
Rapture apical subpleural bleb or bullae
 Secondary
 Chronic obstruction-COPD account for 50%
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14. Cont..
 Bronchiectasis
 Lung malignancies
 Lung infection- pneumocystic jirovecii, TB, bacterial
pneumonia,
 Genetic disease-cystic fibrosis, marfans syndrome ,
homocystinuria
 Cystic lung disorders – lymphangioleimyomatosis, diffuse
Langerhans cell histiocytosis, lymphocytic interstitial
pneumonia, thoracic endometriosis (catemanial
pneumothorax)
 Smoking is a mojor risk for primary & secondary
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15. Tension pneumothorax
 Life threatening & can develop from any type of a
pneumothorax.
 Air enters the pleural space through a one way mechanism
→air cannot escape.
 Air accumulate in the pleural space with each inspiratory
phase→ ↑ pleural space pressure → shifting of
mediastinum→ compression of the contralateral lung →
hypoxia.
 Eventually compress of the vena cava & atria →↓ venous
return to the heart & ↓ cardiac function .
 Leads to rapid cardiopulmonary collapse.
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16. Cont..
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17. Cont..
 Tension pneumothorax:
 Spontaneous & traumatic pneumothorax can develop into a
tension pneumothorax if the defect that allow air into the
pleural space becomes one way valve (air enters during
inspiration but cannot escape during exhalation which
causes rising pressure in the pleural cavity , shifting the
mediastinum to the contralateral side
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18. Cont..
 Simple
 Mediastinum remains central
 Clinical condition stable
 Can wait for CXR to confirm diagnosis
 Tension
 Progressive build up of air in the pleural space, causing
a shift of the heart and mediastinal structures away
from side of pneumothorax
 Clinical condition unstable
 Do not wait for CXR to confirm diagnosis
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19. CLASSIFICATION
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20. Cont.…
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21. RISK FACTORS/CAUSES
 Sex-men are at high risk
 Smoking
 Age
 Genetics
 Lung disease
 Mechanical ventilation
 History of pneumothorax
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22. CLINICAL PRESENTATION
 Shortness of breath of varying degree depending on the
size of the pneumothorax & patients factors e.g. lung
disease.
 Sudden onset chest pain, often pleuritic in nature , small
spontaneous pneumothorax can be asymptomatic
particularly in younger patients.
 O/E there will be:
Hyperresonance on percussion
Reduced or absent breath sound on auscultation
Reduced chest expansion
Decrease in tactile fremitus
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23. Cont..
 In cases of tension pneumothorax:
Patients will be hypoxic
Tachycardiac
Hypotensive
Potential distended neck vein
Tracheal deviation away from the affected side
Cyanosis
Tachypnea-abnormal rapid breathing
 Cardiovascular-jugular venous distension
-Pulsus paradoxus-↓ stroke volume
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24. Cont..
MNEMONIC
 Signs & symptoms of tension pneumothorax is summarized
with P-THORAX
 P-Pleuritis pain
 T-Tracheal deviation
 H-Hyper- resonance
 O-Onset sudden chest pain
 R-Reduced breath sound
 A-Absent fremitus
 X-X-ray showing collapes
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25. INVESTIGATION
 Initial investigation should run alongside this(expect for
cases of tension pneumothorax when urgent needle
decompression is required in 2 or 3rd ICS
 Tension pneumothorax is a clinical diagnosis &
management should not wait for imaging confirmation
1 Plain chest radiograph(CXR)
 The size of pneumothorax is determined by measuring
interpleural distance at the level of hilum.
 Should be performed in upright position (when possible)
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26. Cont..
General findings
 White visceral pleural lining defining lung & pleural air
 Bronchovascular markings are not visible beyond pleural edge
 Deep sulcus
 Ipsilateral hemidiaphragm elevation
Tension pneumothorax
 Potential mediastinum shift
 Trachea deviation
 Ipsilateral hemidiaphragm flattening
 Ribs are spread a part
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27. Cont..
2 Routine blood –FBC
-CPR
-U & Es & clotting
 Arterial blood gas (ABG)
 Electrocardiogram (ECG)
3 CT imaging
 determine underlying cause in context of trauma &
concurrent injuries
 Findings –air in the space , can evaluate the location ,
pleural pathology & lung disease
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28. Cont..
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29. Cont..
4 Ultrasound
 Presence of a lung point –boundary between the lung &
pneumothorax
 Lung sliding will be absent at the location of pneumothorax
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30. MANAGEMENT
 Management is determined by both size or type of the
pneumothorax & patient factor.
 As a minimal ensure all patient have sufficient analgesia &
started on oxygen if required.
 For patient with chest drain inserted ensure it is attached
to underwater seal.
INITIAL MANAGEMENT
 Primary spontaneous pneumothorax those that are small
(<2) & asymptomatic patients should be admitted for
observation.
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31. Cont..
 Symptomatic or large primary pneumothoraces needle
decompression should be attempted placed in 2nd or
3rd intercostal spaces at the midclavicular line if no
improvement chest drain via seldinger technique to be
placed
 5th ICS space in the anterior or midaxillary line in SAFTEY
TRIAGE is another option-followed by chest tube
placement.
 Small spontaneous pneumothorax will required
admission for observation with a low threshold for
attempting needle decompression ,
 Those that are large & symptomatic required chest drain
via seldinger technique to be placed.
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32. Cont..
 Traumatic pneumothoraces will normally require surgical
chest drain insertion or otherwise admitting for observation
if small & asymptomatic.
 Importantly there is no role in needle decompression in
traumatic non-tensioning pneumothoraces.
 For traumatic tension pneumothoraces either needle
decompression (in 5th intercostal space mid-axillary line)
or finger thoracostomy is required prior to chest drain
insertion.
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33. Cont..
FURTHER INVESTIGATION
 Considered in those with persistence air leak or failure of lung
re-expansion.
 Spontaneous cases medical pleurodesis is often trailed
resulting in partial obliteration of the pleural space through
introducing irritant agent aiming to prevent recurrences
,alternatively Heimlich valve can be trailed a one way valve
attached to a chest tube & enable evacuation of air that is not
under tension.
 Those failing these intervention or in traumatic cases should ne
considered surgical intervention which includes video
assisted thoracoscopic surgery (VATS) for pleurectomy +/-
pleural abrasion or open thoracostomy& pleurectomy .
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34. COMPLICATIONS
 Hypoxemic respiratory failure-low level of oxygen
 Respiratory or cardiac arrest-heart suddenly stop pumping blood
 Hemopneumothorax-combination of pneumothorax &
hemothorax.
 Bronchopulmonary fistula-abnormal communication btwn
bronchial tree & pleural cavity
 Pulmonary edema –following lung re-expansion
 Empyema-collection of pus in the pleural cavity
 Pneumomediastinum-presence of air in mediastinum
 Pneumopericardium-presence of air in pericardium
 Pneumoperitoneum-presence of air in peritoneal cavity
 Pyopneumothorax-accumulation of gas & pus in pleural cavity
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35. Cont..
COMPLICATIONS OF SURGICAL PROCEDURE
 Failure to cure the problem
 Acute respiratory distress or failure
 Infection of the pleural spaces
 Cutaneous or systemic infection
 Persistent air leak
 Re-expansion pulmonary
 Pain at the site of chest tube insertion
 Prolonged tube drainage & hospital stay
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36. DIFFERENTIAL DIAGNOSIS
 Pulmonary embolism(PE)
 Hemothorax
 Pleural effusion
 Myocardial infarction
 Pericarditis
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37. R
•Right lung more translucent than left
•Faint line just visible (zoomed view to follow)
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38. •Pencil-thin white line
running parallel to chest
wall
•No lung markings lateral
to the line
Blade of right scapula
Right pneumothorax
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39. Simple Left Pneumothorax
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40. Simple Left Pneumothorax
No mediastinal shift
Small pleural
effusion
(common
finding)
Visceral
pleural line
(zoomed
view on next
slide)
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41. Note absence of
lung markings
lateral to this line
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42. Pneumothorax with rib fractures
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43. Tension right pneumothorax
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44. Tension right pneumothorax
Mediastinal shift to
left 5/29/2023
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45. HEMOTHORAX
 Hemothorax is the accumulation of blood in the intrapleural
spaces.
 Bleeding is usually from intercostal artery in lacerated chest
wall or from underlying contused lung, heart or great vessel.
 Massive hemothorax is bleeding of more than 1500ml into
pleural cavity
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46. EPIDEMIOLOGY
 Hemothorax can be associated with a single rib fracture.
 Approximately 150,000 deaths occurs from trauma each
year.
 Approximately 3times this number of individuals are
permanently disabled because of trauma.
 Chest injuries occurs in approximately 60% of multiple
trauma cases.
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47. PATHOPHYSIOLOGY
 Accumulation of blood in the pleural space caused by
bleeding from; penetration or blunt lung injury, chest wall
vessels or intercostal vessels.
 Hemothorax is manifested by;
 >hemodynamic response-hypovolemic shock rapid
bleeding.
 >respiratory response-slow bleeding.
 Blood that enters the pleural cavity is exposed to the
motion of the diaphragm, the lungs, and other intrathoracic
structures.
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48. CLASSIFICATIONS
TRAUMATIC HEMOTHORAX
 Occurs due to penetration injury of the lungs, heart, great
vessels, or chest wall
non Traumatic hemothorax
 Malignancy pleural diseases(sarcoma, angiosarcoma)
 Bleeding disorders(hemophilia, thrombocytopenia, rupture of
thoracic aorta)
 Necrotizing infection
 Pulmonary embolism with infarction
Iatrogenic hemothorax
 Causes;
Central venous catheterization
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49. Cont..
 Injury during trans lumber aortography
 Thoracocentesis
 Pleural biopsy
 Trans brachial biopsy
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50. CAUSES OF HEMOTHORAX
 Traumatic
 Infection/infestation
 Congenital
 Degenerative
 Neoplastic(benign/malignant)
 Rib fractures associated with pneumothorax
 Iatrogenic
 Tuberculosis
 Non pulmonary intrathoracic vascular pathology(e.g.
Pancreatic pseudocyst, splenic artery aneurysm)
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51. Clinical presentation
 Restlessness
 Hypovolemic shock
 Tachypnea
 Dyspnea
 Cyanosis
 Diminished breath sounds on affected side
 Hypo resonance(dullness on percussion) on affected side.
 Chest wall deformity
 Crepitus upon palpation over fractured ribs
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52. investigations
 Imaging studies
X-ray
USG(ultrasound sonography test)
CT chest
Angiography
MRI(Magnetic resonance test)
Thoracoscopy
Nuclear scan
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53. management
 ABC of resuscitation
 Large bow cannular &begin IV fluids-crystolliods
 Vital check up including SPO2
 Intercostal drainage tube thoracostomy
 Large bore tube in 5th spacing between mid and posterior axillary
lines
 Can be done before x-ray
 Draining of blood from chest cavity
 Thoracostomy(indicated when total chest tube output exceeds 1500ml
within 24hrs)
 Video assisted thoracoscopic surgery(VATS)
 Shock care due to blood loss
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54. 5/29/2023
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55. 5/29/2023
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56. complication
 Clot retention
 Pleural infection
 Pleural effusion
 Fibrothorax
 Collapsed lung
 Respiratory failure
 Hemorrhagic shock
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57. EMPHYEMA
DEFINITION
 Accumulation of pus in pleural cavity.
 Emphyema come from Greek word Empyein which means
pus-producing suppurates
 Also called Pyothorax
 Its also a secondary disease to other underlyind diseases
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58. EPIDEMIOLOGY
Etiology
Local cause
Chest causes; thoracic wall abscess
Penetrating wound
Oesteomyelitis of ribs
Pleural cause Pneumothorax
Hemothorax
Pulmonary cause Lung abscess
Bronchitis and Pneumonia
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59. Cont..
Latrojenic causes Pasthoractomy
Esophageal perforation
Systemic cause Septicaemia
Bacteriology ; Strep. Pneumoniae,H.influenza and Staph. Aureus
STAGES IN EMPYEMA FORMATION
Stage 1 Exudative stage
Stage 2 Fibrino purulent stage
Stage 3 Organizing stage
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60. STAGE 1 EXUDATIVE PHASE
This is purely on inflammatory process in which there is
increase in permeability of small blood vessesls leading to
exudation of fluid in the pleural cavity.
The fluid is very thin with low cellular content.
Approximately in 7 days
STAGE 2 FIBRINO PURULENT STAGE
This is whereby there is fibrin clot and fibrin membranes in the
pleural cavity leading to fluid loculation
From day 7 to 21 days
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61. CONTI…….
STAGE 3 ORGANIZING STAGE
Proliferation of fibroblasts on the pleural surface,which forms
covering preventing adequate lung expansion.
There is also scarring of pleural membranes with possible
inability of the lung to expand
Takes about 4 to 6 weeks
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62. TREATMENT &
 Treatment of the underlying cause of precipitating factor
 Mild cases –observation is appropriate
 Patient with discomfort –give high oxygen concertation
 Use of empiric broad spectrum antibiotic
 Extensive phase -2cm intravascular incision bilaterally can
reduce further subcutaneous expansion
 In severe cases ICT on one side or both sides placement
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63. DIFFERENTIAL DIAGNOSIS
 Esophageal rapture
 Pneumothorax
 Tracheal /lower/diaphragm perforation
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66. 5/29/2023
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67. AETIOLOGY
 Trauma to the chest
 TB
 Uremia
 Idiopathic pericarditis
 Infectious disease
 Anticoagulation
 hyperthyroidism
 Connective tissue disease
 Post pericardiotomy syndrome
 Malignant disease
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68. CLINICAL FEATURES /SIGNS
 Hypotension/shock(rapid weak pulse)
 Grossly distended neck vein (raised JVP)
 Elevated central venous pressure
 Severe distress
 faint heart sound
 Penetrating injury in the proximity to the heart
 The classic findings /a hallmark signs of beck triad
1Hypotension
 2 Distended neck vein
 3 Faint heart sound
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69. BECKS TRAID
 Collection of three clinical signs associated with pericardial
tamponade which is due to excessive accumulation of fluid
within the pericardial sac
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70. SYMPTOMS
1 Sharp pain in the chest –pain may radiate to the nearby parts
of the body like abdomen ,arm ,neck & shoulder
2 trouble breathing /breathing rapidly
3 fainting ,dizziness/light headache
4 changes in skin color
5 heart palpitation
6 fast pulse
7 Altered mental status /confusion
8 decreased urine output
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71. DIAGNOSI/INVESTIGATION
 History taking
 Physical examination
 Echocardiogram
 Chest x-ray
 Computerized tomography
 Heart catheterization
 Ultrasound
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72. MANAGEMENT
 Removal of the fluid around the heart
 Its done through pericardiocentesis –the procedure use a
needle that is inserted into the chest until in enters the
pericardial sac & the fluid is aspirated
 Surgery
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73. COMPLICATION
 Shock
 Heart failure
 Death
PERICARDIOCENTESIS & SURGERY COMPLICATION
 Bleeding
 Injury to the heart chambers
 Heart attack
 Infections
 Injury to nearby organs
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74. DIFFERENTIAL DIAGNOSIS
 Cardiogenic shock
 Constrictive pericarditis
 Pneumothorax
 Pulmonary embolism
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