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NUR3120 Respiratory emergencies - Coggle Diagram
NUR3120 Respiratory emergencies
Hemothorax/pleural effusion
Types
Small: minimum of 300ml in pleural cavity to be seen in the x-rays
Large: reduction in vital capacity
Cause hypoxia and hypercapnia
Manifestation
Acute pleural pain, dyspnea
Small: no findings or shifting dullness on percussion
Large: decreased chest movements, shift of mediastinum, dullness on percussion of breath sounds
Causes
Exudative
Transudative
Treatment
If hemathorax equal or larger than amount to obscure costrophrenic sulcus, drained by tube
thoracostomy
(chest tube drainage)
Greater than 1000ml of blood exacuated --> Surgical exploration
Bleeding continues for 2-4hrs in 150-200ml
Persistent blood transfusion required to maintain hemodynamic stability
Pneumothorax
Collection of air in pleural cavity
Diagnosis
CT Xray: darkness because of accumulation of air,
Small pneumothorax --> missed out., Rule out pneumothorax with CT [scan]
Mediastinal shift
Diaphragmatic depression
Flattened ribs
Types and causes
Spontaneous: rupture of bulla(e) on surface of lungs
Bronchial asthma, COPD, tuberculosis
Chest trauma: negative pleural pressure allow air to enter
Small
: asymptomatic
Large
: acute pleural pain, dyspnea
Decreased chest movements
Shift of mediastinal structure
Hyper-resonance on percussion and absent breath sounds
Tension pneumothorax
Life threatening condition
One-way valve at point of rupture in lung: air go in, cannot come out, builds up. Prevents lung from inflating fully
Air enters during expiration, air pressure within thorax higher than atmospheric pressure, compressing lung --> displace mediastinum and its structures --> cardipulmonary impairment
May cause compression of other lung
Complications
Venous + cardiac output decrease leading tohypotension and tachycardia
Hypoxemia due to alveolar collapse
Reexpansion pulmonary edema (drain air too fast. Sudden decrease in volume --> long duration, high pressure gradient) May be related
Reperfusion injury
First just waterseal, no suction. Then fail to reexpand --> apply suction
Bronchopleural fistula
: formation of fistula or sinus tract between bronchus and pleural space. Continuous flow of air into pleural vacivty making it worse
Management
Oxygen
supplemental O2 speeds absorption of air from pleural space
Observation of stable patients
If 4 hrs no enlargement/deterioration --> go home
Secondary and iatrogenic, hospitalize and observe carefully
If deterioration --> chest drain
Simple aspiration
with narrow bore tube. Or chest tube drainage (better rate of immediate treatment success)
For recurrent pneumothorax,
pneumothoraces
Inject chemical into parietal and visceral pleura. Place obliterated, air cannot enter
Pulmonary edema
Life threatening emergency in which excess fluid accumulates in lungs
Characterized by extreme breathlessness
Manifestations
Anxiety, profuse perspiration
Acutely breathless
Tachypnea, tachycardia
Wheezing, crepitations
Cough
-productive of frothy, blood tingued sputum. Copius in amount
Diagnosis
Chest Xray: Kerley-B lines: 1-2cm long horizontal lines at sides of the side of lungs beginning at the costophrenic angle
The higher these lines, the more severe it is
Causes
Increased venous hydrostatic pressure
(left ventricle failure --> most common) reduced plasma osmotic pressure, hypoalbuminemia
Altered alveolar capillary membrane permeability
Acute respiratory distress syndrome (ARDS), diffused alveolar damage, exudative phase
Increased capillary pressure
If pressure >25mmHg
If primary capillary pressure more than 25mmHg (normal 15)
Increased filtration of fluid into interstitial space (space between 2 alveoli), gas exchange worsen
Accumulation of fluid disrupts intercellular membranes, accumulation of fluid in alveoli
Pulmonary embolism
Causes
Thrombus (most common)
Air
Fat
Amniotic fluid (post natal females)
Parasites
Septic emboli
Tumor (renal cell carcinoma, from renal vein to vena cava then lungs)
Risk factors
Virchoww's triad
Venous stasis
--> prolonged bed rest, immobilized, pregnancy, low cardiac output
Hypercoagulability (increased coagulation tendency)
--> tissue injury after surgery, trauma
Malignancy
Vessel wall inflammation
Blockage and obstruction of pulmonary vessel by blood borne substance
Common cause of unexpected death
Often missed due to non-specific symptoms
Manifestations
Small emboli
Effort dyspnea,
tiredness
syncope
cardiac arrhythmias
Massive emboli
Sudden severe central chest pain
Marked tachypnea, dyspnea, shock
Classic triad of sudden onset of dyspnea, pleuritic pain, hemoptysis
Swollen tender, warm calf
Auscultation: inspiratory crackles, pleural rub, wheezing
ECG: sinus tachycardia
I: Deep S wave
III : Deep Q wave, inverted T wave
Microthrombi form but continuously removed in venous system
Pulmonary vessels act as filters --> remove emboli from reaching arterial system
Large clots can dmg lung/heart function
95% arise from thrombi in deep veins of LL
Hemodynamic changes: obstruction increase because of embolus,
Change in V/Q ration
Perfusion distal to obstruction will reduce
Hypoxia will lead to alveolar ischemia, then collapse, release of infalmatory response
Pulmonary infarctions, occurs in 10% of cases