ISPP 2015

Career Opportunities in Pharmacy

[Music] all right now we’re going to move on to some other pulmonary life threats the next one is open pneumothorax so open pneumothorax is kind of interesting physiologically this happens when you have a large open defect in the chest wall and if we all remember our fluid flow physics when you have a a tube and you’re trying to determine the rate of flow through that tube the primary determinant of flow is going to be the radius of the tube and then the second most important determinant is the length so if you think about your trachea as a tube and you think about the hole in your chest wall as a tube you can imagine the chest wall is a much shorter tube right it’s a lot smaller than the trachea so when that wound goes up to two-thirds of the tracheal diameter it doesn’t have to be the size of the trachea or bigger than the trachea it can still be smaller because the tube is so much shorter when that happens inspiration is going to preferentially pull air through the wound into the pleural space rather than going down the trachea and into the lungs so if you have a large enough defect here you’re not going to pull air through the bronchial tree the way you’re supposed to you’re gonna pull air in directly through the wound when you breathe now as you can imagine if you’re just sucking air into your pleural space through a hole in your chest that’s going to render your ventilation pretty ineffective so this can result in lethal hypoxia and respiratory failure if it’s not treated promptly so again large wound in the chest wall on physical exam anything bigger than two-thirds the size of the trachea is gonna cause air to preferentially flow into the wound this is also known as a sucking chest wound and that’s because these wounds make a delightful sucking sound during the respiratory cycle you can actually hear air being pulled in through the wound and it goes with every respiratory effort it’s going to cause hypoxia and respiratory distress and you don’t need radiologic confirmation for this you can actually see the wound you can hear the sucking sound you can appreciate the patient’s respiratory distress you’re going to go ahead and treat it so the treatment is very satisfying ly simple you basically just place an occlusive dressing over the wound and what’s going to happen when you do that is when the patient breathes in now you’ve got the whole occluded so it’s going to suck the dressing up against the chest wall but it’s not going to let any air go through the wound well if air can’t get through the wound where it’s where’s it going to go now it’s going to go down through the trachea into the bronchial tree where it belongs however we want to make sure that we allow air to escape from this wound during exhalation because you don’t know what kind of injury there is to the underlying lung and you don’t want to create a tension pneumothorax so the way we do this is by securing the occlusive dressing only on three sides and that creates a one-way valve effect so when the patient breathes in no air goes through the wound but when they breathe out air can escape out through the wound if it needs to and that’s going to prevent the development of attention in the thorax these patients always need chest tubes for definitive management again the lungs not going to be able to re-expand and heal unless you restore the negative inner thoracic pressure which is accomplished with a chest tube and there is a high incidence of underlying injury you can imagine that any kind of traumatic mechanism that makes a big hole in your chest wall is going to be very likely to be associated with other pathology so these patients often end up going to the operating room for other reasons all right next pulmonary life threat to talk about is flail chest flail chest occurs when you have multiple rib fractures so basically if you have multiple fractures of ribs that are adjacent to one another and the fractures are present in two different locations you get a section of rib that is discontinuous from the rest of the thoracic cage well what’s going to happen to that section of rib it’s not tethered down to the other ribs now so it’s not going to move normally during the respiratory cycle it’s going to actually move paradoxically so normally when you breathe in your ribs follow that bucket handle motion and sort of expand but now you’ve got a section of chest wall that’s not going to do that it’s going to go and suck up against the lung during inspiration this is going to directly impair ventilation right because yet now you have a section of rib that’s floating around doing its own thing and it’s gonna also be strongly associated with underlying pulmonary contusion because this section of rib one it got broken somehow so clearly there’s going to be a high likelihood of transmission of energy to the underlying lung and two you are repeatedly injuring the lung by pulling this section of rib up against it over and over again so patients with flail chest you’re going to be able to physically see a chest wall deformity on your clinical exam this is not going to be a subtle finding you’re going to see that paradoxical chest wall movement in the area of affected rib you’re going to see infiltrates on your chest x-ray which are suggestive of underlying pulmonary contusion and the treatment for this in the EEG is really going to be supportive we’re going to want to make sure that we provide the patient with supplemental oxygen that we maintain their oxygenation that we intubate and mechanically ventilate them if they are in significant respiratory distress but there’s not really any definitive treatment that we can offer for this in the edie setting in many cases these patients with supportive care will just go on to heal their rib fractures and be fine although there are situations where surgical fixation of the chest wall might be necessary [Music]

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