Differential diagnosis of acute thoracic disorders Acute disorders •TRAUMATIC – 20-25% mortality –Respiratory insufficiency –Hemorrhage – –NON-TRAUMATIC – – Trauma Penetrating Blunt Traumatic •Clinical examination – ABCD –Inspection, palpation, auscultation, percussion • •Imaging •Blood tests • Open pneumotorax •Management – closure of defect on thoracic tube • •CAVE: defect > 2/3 of trachea diameter – life threatening • Closed pneumothorax •Hyper resonant percussion • •Therapy – thoracic tube – 4.-5. ICS anterior axillar line Tension pneumothorax •Air retention -> collapse of the lung -> mediastinum shifting to healthy side -> respiratory failure • •Therapy – first aid – thick needle in 2nd ICS in medio-clavicular line –Thoracic tube Rupture of trachea or large bronchi •Clinical examination: stridor, emphysema, tachycardia, hypotension, pneumothorax • •Bronchoscopy before intubation in stable patient • •Therapy: surgery Hemothorax •Small <300ml – observation • •Medium 300 – 1 000ml – thoracic tube • •Massive >1 000ml or >300ml/hour – urgent thoracotomy Burns •ARDS •Lung edema • •Clinical examination: dyspnea, cough, cyanosis, hemoptysis, hypotension, tachycardia • •Stenosis of airways after healing Contusion •Lung – CAVE: subcutaneous emphysema with absence of visible chest-wall injury • •Heart – right side, pulmonary outflow tract, root of aorta • •Therapy: analgesia, rest, O2, antiarrhythmics, sedation • Heart tamponade •Paradox pulsation •Triad of Beck: –neck veins distension –Hypotension + bradycardia –Distant, muffled heart sounds – –ECHO • Injury of great vessels •Rupture of aorta • •Aortal dissection – DeBakey classification • •CAVE: fracture of scapula, clavicula, 1st and 2nd rib Injury of rib •„egg shell“ type •Rib fracture – CAVE: doesn´t have to be seen on X-ray •Costo-vertebral dislocation •Series fracture •Parallel („window“) fracture – flail chest – T: elastic bandage • •CAVE: injury of abdominal organs • • Image result for rupture of esophagus Injury of esophagus •Clinical examination: neck emphysema, pneumothorax without rib fracture • •CT with p.o. contrast Injury of diaphragm • • •Common on left side, unusaul on right – liver • •Be carefull about the spleen during surgery Symptoms •Pain •Dyspnea •Hypotension + tachycardia •Bradycardia – tamponade •Hypoxia •Hypercapnia Therapy •Simple rib fracture, mild contusion – analgesia, rest, O2 • •Pneumothorax, hemothorax, chylothorax – drainage • •Bigger injury, COPD, smokers - ATB Non-traumatic disorders •Aspiration •Spontaneous pneumothorax •Pleural effusion •Pneumonia •Postoperative complication Non-traumatic disorders •Acute esophageal obstruction •Esophageal hemorrhage •Esophageal rupture •Hiatal hernia •Mediastinitis •Pulmonary embolism • Pleural effusion •Transudate • •Exsudate • • Pyothorax • Hemothorax • Chylothorax • Cause •Transudate –heart failure, PE, liver cirhosis •Exsudate –Infection, TBC –Malignancy –Chylothorax –Perforation of esophagus How to distinquish •Puncture – appearance • •Light criteria • • • • •Microbiology + cytology •Chest pain •Dyspnea •Coughing •Hemoptysis Patients history •Pain –When it started –How long does it hurt –Location –Propagation –How it looks like –What causes the pain –Is there any relief position –What are the other symptoms (dyspnea, nausea, vomiting, sweating) – Clinical examination •Sight –usage of help respiratory muscles –Colour of the skin – way of speaking – shortness of breath –Breathing frequency •normal – 12 – 20 •> 25 – tachypnoe •< 12 bradypnoe • • • • Image result for ortopnoická poloha •Percussion –resonant - normal – –hyper – resonant – –dull • Image result for pneumothorax Image result for fluidothorax •Auscultation –Alveolar – normal –Week – –Added sound – stridor, wheezes, crackles –https://en.wikipedia.org/wiki/Respiratory_sounds# – Other examination •Blood tests – troponin, Hb •SpO2 – 95 – 100% •ASTRUP • • • • • • • •ECG •X-ray, HRCT • https://www.stefajir.cz/files/Astrup.jpg Chest pain •Sharp •Dull • •Persistent •Conected to breathing What can be the cause •Patient history • •Clinical examination – cyanosis, heart rate, blood pressure • normal doesn´t mean not severe • Cause •ECG • •SpO2 • •Blood test: TnT, D-dimers, NTproBNP, blood count, Urea, Kreat., AMS, koag., CRP • •Imaging • Chest pain •Ethiology: •Cardiovascular – Ischemic – Non-ischemic •Non-cardiovascular • Pulmonary/Pleural • Gastrointestinal • Pain of the chest wall • Verterbogenous • Other - psychiatric Chest pain •Patient A: –Young man – 25 years old –195cm, 90kg –Sudden chest pain –After work-out –Conected to breathing – •Patient A – clinical examination: –Breathing frequency 16/min –No cyanosis –Mild dyspnea – –SpO2 – 95% • Image result for spontaneous pneumothorax Diagnosis? •A: Pneumonia •B: Spontaneous pneumothorax •C: Tuberculosis •D: He is healthy Chest pain •Patient B: –Man 62 years –Patients history: hypertension, smoker 20cig/day 40 years –Sudden start –Dull, constringent pain Dyspnea •How it looks like: –Orthopnea –Tachypnea > 25/min –Hyperventilation –Hypoventilation Cause? •Cardial •Pulmonary •Head – neck •Neuromuscular •Mechanical •Metabolic •Anaemia •Psychogenic What is the cause •Patient history –Dynamics: acute, recidivans , chronic –Is it worse with exercise? NYHA –Is it worse in lying position? –Does it appear at night? When? –Other symptoms? Fever, pain What is the cause •Clinical examination: –Vital functions –Inspection –Auscultation What is the cause •ECG, ASTRUP, X-ray • •Lab: blood count, electrolytes, gly, urea, kreat, liver enzymes, TnT, D-dimers Firts aid •O2, nitrates, antishock •Β2-mimetics • •ICU • What next? •ECHO • •CTAG + CT of lungs • •Laryngoscopy • •Spirometry Cough •Acute •Asthma •Infection •Pleuritis •Aspiration •Acute heart failure Cough •Chronic •COPD •Bronchiectasies •Interstitial diseases •Carcinoma •Left-heart failure •Drugs •GERD •Psycho • What is the cause •Patient history –Productive or dry? –What provoces cough? –Chronic medication? –Smoking? –Work? What is the cause •Auscultation • •X-ray • •Spirometry • •ECG Take home message •Patient who coughs longer than 3 weeks should have X-ray, longer than 6 weeks BSC. •If it is negative think about asthma, COPD. •If lying possition provoces coughing think about GERD •Smoker – cough other than usuall – think about carcinoma •Do not forget about TBC Hemoptysis Is it really hemoptysis •Pseudohemoptysis • •Hematemesis Cause •Massive – 600ml /24h • •Ex-sanquinating > 150ml /h Cause •Inflammation •Cardiovascular •Malignancy •Vasculitis •Pulmonary Embolism •Bleeding diathesis •Aneurysm formation •Broncholithiasis •Trauma •https://www.youtube.com/watch?v=_6sFa79u6FQ • Nodal syndrome •One location •Generalised • •Infection •Malignancy •Other Nodal syndrome •Patients history –How fast does it grow? –Is it painfull? –Other symptoms: sweating, weight-loss, itching, fever, cough, dyspepsia Nodal syndrome •Clinical examination –Palpation < 1,5cm – – •USG, CT • •Histology – needle, open, surgical endoscopy • – • Image result for retrosternal goiter Thyroid disease Goiter •Function (hyper, hypo, eufunction) •Parenchyma – nodular, diffuse •Benign x malignant x inflamatory •Endemic •Strumigens •During pregnancy • Malignant goiter •Anaplastic • •Folicular • •Papilar • •Medular • Examination •Endocrinologist –Blood tests: fT3, fT4, TSH, TPOAb, TRAb, TgAb –USG –Scintigraphy –CT if retrosternal Indication to surgery •Malignancy • •Normal function nodal goiter in kids and young • •Mechanical obstruction • •Toxic goiter with no answer to medication Thank you for attention