CARDIO

SUMMARY OF

INDEX
FRACTURE RIBS
EMPYEMA THORACIS
HEMOTHORAX
PNEUMOTHORAX
PULMONARY EMBOLISM
CARDIAC ARREST
CARDIAC TAMPONADE
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 TRAUMAS:
1) FRACTURE RIB ® blunt trauma.
2) PNEUMOTHORAX ® blunt trauma
Simple (isolated) Flail Chest except open type is penetrating.
3) HEMO-THX & CARDIAC TAMPONADE
DEF. · Fracture 1 or more ribs. · Fracture 3 or more ribs. ® blunt or penetrating

· at 1 site only. · > 1 site ® creating a flail segment.

ETIOLOGY · Direct ® Blunt trauma. (directed inwards ® Visceral inj. is common)

· Indirect ® Antero-post. Crush ® fracture at angle. (directed outwards ® less visceral inj.)

C/P & ORTHO SCHEME + ­ Pain on 1) Dyspnea, Cyanosis

COMPLICATIONS breathing or coughing. 2) Tachycardia.
“TENDERNESS ON FRACTURED RIB” 3) Restlessness & confusion.
4) Engorged Neck veins.

COMPLICATIONS · Lung contusion + injury of br. plexus. · PARADOXICAL RESPIRATION® Diagnostic cl. sign.
· Pneumothorax, hemothorax. · PENDULAR RESPIRATION ® switch of gases bet. 2 lungs
3 Ps ® ­CO2 in blood ® hypoxia.
· Surgical emphysema.
· PULM. CONTUSION (main COD) or Mediastinal flutter
· Rupture spleen – liver. (dt kink of great vs. ® Cardiac arrest)

INVEST. · CXR ® diag. & exclude comp. · CXR ® fractured rib!

· Lower ribs ® Abd. U/S.

TTT. CONSERVATIVE : ANALGESICS · ER. STRAPPING “Elastoplast” ® fix the flail segment.
Stove in chest = Flail chest but · NSAID. · ETT + MECH. VENTILATION (PEEP) for 2 wks. till healing.
the flail segment is sucked & fixed · IC nerve block. · OR + IF ® only if Thoracotomy is indicated.
over the lung ® lung laceration. · Epidural analgesia. (eg: lung contusion) 1
 EMPYEMA THORACIS
DEF. Accumulation of Pus in the pleura.
TYPES ACUTE
ETIOLO · M/C CAUSE ® on top
of pneumonia.
GY
· M/C ORG. ® pneumo-
cocci, Staph. & Strept.?
How to diff. see last p.!
· LOCAL ® pyogenic
lung or liver ds.
· SEPTICEMIA, PYEMIA.
SYMPT. · Toxemia. (FAHM-R)
· Hx. of chest inf.
· Chest Pain & dyspnea.
SIGNS as Hemothorax
COMP. SEPTICEMIA, PYEMIA,
SPREAD TO THE SURR. +
“EMPYEMA NECESSITANS”
SC abscess with expansile
impulse on cough…
necessary for drainage.
HEMOTHORAX PNEUMOTHORAX
Accum. of Blood in pleura. Accumulation of Air in the pleura.
CHRONIC PATHOLOGY?! SEE BELOW SIMPLE OPEN TENSION
1) MIS-MANAGEMENT OF · TRAUMATIC ® closed or · TRAUMATIC ® Blunt (SUCKING CHEST WOUND) BLUNT OR
ACUTE EMPYEMA: penetrating. trauma. PENETRATING
PENETERATING
TRAUMA
· Faulty drainage: · POST-OP. ® cardiac, esoph, · SPONT. ® Rupture TRAUMA
® Too late or too low. pulm, central venous line. emph. bulae /TB cavity.
“Communication bet. pleural ¯
(blocked by diaph.)
· PATH ® Tumor, leaking · IATROGENIC ® ETT space & atmosph. ® air enters Comm. bet. lung
® Too high drainage. aneurysm. or Insertion of central during insp. 7 comes out during & visceral pleura
(independent area) venous line. exp. ® lung collapse” with a valve like
· INADEQ. post-op. care. action
2) UNDERLYING CHEST DS.
(Lung Abscess - OM of rib)
C/P
· Dyspnea, cyanosis. as (open) +
Sinus discharging pus Chest pain Chest pain &
· Restleness, Confusion. ENGORGED NV
(‫)ﺧﺮم‬ & Dyspnea Dyspnea
· Tachycardia, Shock.
SIGNS OF FIBROSIS: · ¯ CHEST MOV. · ¯ CHEST MOV. The same + :
· Crowding of ribs. · ¯ TVF. · ¯ TVF. · Harsh noisy sound of As Open
· Elevation of diaph. · DULLNESS. air through ! defect.
· HYPER-RESONANCE.
· Shifted mediastinum · ¯ AIR ENTRY. · Shifted mediastinum
to the affected side. · ¯ AIR ENTRY. to the opp. side.
· ± SHIFTED MEDIAST IF MASSIVE!
BRONCHO-PLEURAL HYPOVOLEMIC SHOCK AS FLAIL CHEST · Lung collapse.
FISTULA if massive.
· Main COD ®
Electro-mech.
dissociation &
2
Cardiac arrest
 EMPYEMA HEMOTHORAX PNEUMOTHORAX
ACUTE CHRONIC SIMPLE OPEN TENSION
INVESTIGATIONS: CLINICALLY DIAG.
· CXR & CT ® as hemothorax · CXR ® Signs of fibrosis. · CXR ® obliteration of costo- CXR: jet black Same + SAME BUT ITS AN ER
+ underlying path. phrenic angle. opacity. ¯
· CT scan ® underlying path. MEDIASTINAL SHIFT
· IC aspiration ® pus. · CT scan chest. NO TIME FOR CXR
· PLEUROGRAM ® site & size
· CBC ® leukocytosis. sinus. · IC aspiration ® blood.

TREATMENT
· THIN PUS ® ASPIRATION. · RE-DRAINAGE BY IC TUBE. 1) IC tube. (as scheme) SMALL AMOUNT ER convert it to DECOMPRESSION
2) OPEN THORACOTOMY & ® spont. absorp. Closed pneumothx. THORACO-CENTESIS
· IC TUBE (AS SCHEME) IF: · DECORTICATION if failed
dt fibrosis. LIGATION OF ! BLEEDING VS.? 1) 1st line = Adhesive WIDE BORE CANNULA
a) Bilateral.
LARGE AMOUNT ext. dressing on 3 of 2ND IC SPACE MCL
b) Rapid re-accumulation. · PLEURO-LOBECTOMY of the a) MASSIVE:
® IC tube it's sides (Vaseline gause)
c) Thick pus. underlying ds. · >1500 ml ¯
(as scheme) to stop the flow of air
· >200 ml/h for 4hrs.
· DECORTICATION if fibrosed & · >100 ml/h for 8hrs. through the defect. IC tube.
multi-loculated ® OPEN (as scheme)
b) CLOTTED, LOCULATED, OTHERS! 2) Then IC tube.
DRAINAGE “THORACITIMY”.
3) DECORTICATION if fibrosis! 3) Wound repair.

PATHOLOGY OF HEMO-THX Scheme for IC tube

1) Bleeding is minimal dt Insertion CARE OF THE IC TUBE

low pr. area ® stops spont.
2) Blood is Never absorbed spont.
® Defrbrination ® clotting
® org. & fibrosis of the pleura
® interferes with pleural mov.
(CLOSED THORACOTOMY)
· 5th IC space MAL under water seal.
· Inserted above the upper border of
ribs. (to avoid injury of vs & ns.)
1) MUST BE OSCILLATING.
2) FOLLOW UP daily by CXR ® Removal of pleural air+ lung exp.
3) B4 REMOVAL ® Clamping for 24 hrs. to asses recurrence.
4) REMOVED during full inspiration.
5) PURSE STRING suture is closed quickly. 3
· Occurs with in the
1st 10 days after DVT.
· 30 % Post-operatively FATAL PE MASSIVE PE INFARCTION
· Majority are lysed in situ.

PATHOLOGY Main pulmonary trunk 1 of its major branches Brs. of pulmonary artery

CL./P SUDDEN DEATH dt · Sever Pain. · Pleuritic Pain. Showers of emboli.

electro-mech. diss. · Sever Dyspnea, Cyanosis. · Dyspnea, Cyanosis. · Periodic attacks of dyspnea.
M/C SOURCE: · Tachycardia, Hypotension. · Hemoptysis. · Fever.
ileac v. thrombosis. · Death with in mins. · FUO.

INVEST. LAB RADIO

1) ABG ® hypoxic / normo-capnic. 4) CXR ® ¯ BVM – RV++
(N) in 50% of pts.
5) V/P ® Defective (P) / Normal (V) (time consuming!)
2) ECG
6) Pulm. angio ® filling defect (invasive!)
3) LAB ® leucocytosis, ­LDH
7) MOST DIAG. ® SPIRAL / TRIPHASIC CT scan

TTT. Catheterization in PA + either: 1) Heparin ® (vascular for details!)

· Suction Embolectomy. 2) IVC filter in case of:
· Thrombolytics IA inj. · Recurrent Showers of emboli. Absolute
(Strepto-kinase) · # of Heparin. indication

· High risk pts. eg cardiac. (relative)

­­ LDH in:
1) Testicular tumors. Lytic therapy is given only
2) Leukemia - Lymphoma. if the pt. is hemo-dynamically unstable!
3) Pancreatitis. & NEVER GIVEN AFTER SURGERY!
4) PE. 4
 ETIOLOGY C/P

Electo-mech. Electro-mech.
Cardiac Others Cardinal Signs
dissociation dissociation
1) Fatal & massive PE. 1) Resp. failure or end stage of shock.
1) M. infarction.
2) Tension pneumothx. 2) Metabolic ® ­K or Ca, RF, LCF. 1) Absent carotid pulse.
2) VF. 1) Tension pneumo thx
3) Cardiac tamponade. 3) hypo-thermia. 2) Absent or gasping resp.
3) Complete AV block. 2) Cardiac Tamponade
4) Prosth. valve obstn. 4) Accidents. 3) Bilat. dilated fixed pupils.

MANAGEMENT "Brain can tolerate hypoxia for only 3-4 min."

ABCD ECG to diff. bet. Of the cause

1) A = Airway patency. Cardiac asystole VF · Tension pneumothx.

2) B = Breathing ® mouth to mouth (on firm surface, nostrils closed) · Cardiac Tamponade.
3) C = Cardiac massage (CPR)® (100 /min)
Ratio ®15 compression: 2 breaths. IV Adrenaline or Ca Cl 1 DC shock =
200j / 200j / 360j
4) D = Drugs: # Intra-cardiac ® tamponade
a) IV fluids & Mannitol ® for Shock. If failed ® repeat
b) Dobutamine, Digitalis ® to maintain BP . ¯ after 1 min. of CPR
c) Low dose dopamine ® for anuria & renal damage. pt. either goes to IV Lignocain
d) NaHCO3 ® for M. acidosis. Normal sinus rythm or VF if refractory.
5
e) Atropine ® for bradycardia.
CARDIAC TAMPONADE MISCELLANEOUS
1) M/C 1ry malignant tumor in ribs ® Chondro-sarcoma.
Ø DEF: bleeding into the pericardium ® compresses the heart
But the M/C in general ® 2ries.
® prevents diastolic filling ® ¯ COP.
2) Fracture involving the 1st rib ® underlying major injury.
Ø ETIOLOGY ® BOTH: Blunt or penetrating trauma.
3) Blood in the pericardium ® globular form.
Ø AMOUNT ® 150 ml inside the pericardium. 4) Tracheal disruptions are immediate life threatening injuries
that can obstruct air exchange ® No 1st aid.
Ø CL./P: 5) Safety margin in rib tumors:
· BECK'S TRIAD ® ­ CVP (engorged NV) / ¯BP / ¯ HS Benign = 2cm. Malignant = 4 cm.
· PULSUS PARADOXUS ® ¯ SBP > 10 mmHg with inspiration. 6) Thoracocentesis ® decompression of pleural space.
· KUSSMAUL'S SIGN ® ­venous pr. on inspiration. 7) Drainage of the IC tube occurs during Expiration
(+ve pleural. pr.)
Ø INVEST. ® Emergent Echo.
How to diff. bet Pneumococcal & Strept. empyema?
Ø TREATMENT:
1) CPR + Immediate Pericardiocentesis of 20 ml of blood. PNEUMO-COCCAL EMPYEMA STREPT. EMPYEMA
2) Open pericardiotomy & suturing the underlying tear. · AFTER the attack. · DURING the attack.
NB: Open cardiac massage isn't done now!! · THICK greenish pus. · THIN yellowish pus.
· EARLY Fibrosis. · NO OR LATE fibrosis.
· Bad prognonsis.