You are called to the bedside of a 72-year-old female on mechanical ventilation for three days, who suddenly develops chest pain. Her face is contorted in pain, and she points to her chest. She has a 40-pack/year history of smoking, and long standing COPD. Vital signs show blood pressure of 85/55 mmHg, heart rate of 120 beats per minute, respiratory rate of 24 breaths per minute, and oxygen saturation of 80% with an FiO2 of 40%. Physical exam reveals absent breath sounds over the left side of the chest, and normal S1 and S2 heart sounds without any murmurs.
What is the next best step in the management of this patient?
Correct Answer D:
A history of mechanical ventilation, especially in addition to underlying lung pathology, and a physical exam showing absent breath sounds on one side of the chest suggests a diagnosis of tension pneumothorax. This patient is hypotensive, tachycardic, and tachypneic, so this is a medical emergency. Before any other imaging or intervention is attempted, an immediate needle thoracostomy performed by inserting a 16-18 gauge needle into the 2nd intercostal space (choice D) of the affected side is required to treat this patient. Once this has been accomplished, a rush of air out of the pleural space is expected. Following needle thoracostomy, a chest tube can be inserted, and chest C-ray can be performed.
→ Obtaining a chest CT (choice A) would be inappropriate at this time, as this patient is clinically unstable (hypotension, tachypnea, tachycardia), and needs immediate treatment. In the context of a pneumothorax, a chest CT can be used if there is clinical uncertainty, and the patient is stable.
→ Obtaining a chest X-ray (choice B) does need to be done, but the first step is needle thoracostomy. Had a chest X-ray been performed, it would have shown deviation of the trachea to the right (the side opposite of the pneumothorax), as well as increased radiolucency on the left side of the chest.
→ Inserting a chest tube into the 5th intercostal space in the midaxillary line (choice c) should be done after the initial needle thoracostomy, as the needle decompression can cause a simple pneumothorax which can be treated with chest tube insertion. When a chest tube is inserted, it should be inserted above the rib, as the neurovascular bundle can be struck if insertion occurs below the rib.
→ Pericardiocentesis - inserting a needle under the xiphoid process, upward and leftward (choice E) is incorrect, as this patient does not have cardiac tamponade. The diagnosis of tamponade would require hypotension, decreased heart sounds, and distended neck veins, as well, lungs should be clear to auscultation, which are not seen in this patient.
Key point:
Sudden onset of chest pain and decreased or absent breath sounds on one side suggest tension pneumothorax. The first step in treatment is insertion of a large-gauge needle into the second intercostal space of the affected side.
The appropriate initial management of deep venous thrombosis is to:
Correct Answer A: Deep venous thrombosis (DVT) is clotting of blood in a deep vein of an extremity (usually calf or thigh) or the pelvis. DVT is the primary cause of pulmonary embolism (PE). DVT results from conditions that impair venous return, lead to endothelial injury or dysfunction, or cause hypercoagulability.
DVT may be asymptomatic or cause pain and swelling in an extremity. Diagnosis is by history, physical examination, and duplex ultrasonography, with d-dimer or other testing as necessary.
All patients with DVT are given anticoagulants, initially an injectable heparin (unfractionated or low molecular weight), followed by warfarin.
An Inferior vena cava filter (IVCF) may help prevent PE in patients with lower extremity DVT and contraindications to anticoagulants or with recurrent DVT (or emboli) despite adequate anti-coagulation. Patients at higher risk of DVT should have compression devices or stockings placed for prevention.
Which one of the following should be considered in geriatric patients when a long airline flight is planned?
Correct Answer E:
“Coach class thrombosis”, deep venous thrombosis (choice E) or pulmonary embolism associated with cramped conditions on long airline flights, is in fact a real phenomenon. However, the risk is small and only those already at increased risk of venous thromboembolism need to be concerned about it.
The known complications of venous stasis must be avoided by the prophylactic use of ambulation and exercises during long flights. Patients at increased risk or presently on antithrombotic medications must be carefully monitored prior to their trip.
A 35-year-old black female has just returned home from a vacation in Hawaii. She presents to your office with a swollen left lower extremity. She has no previous history of similar problems. Homan’s sign is positive, and ultrasonography reveals a non-compressible vein in the left popliteal fossa extending distally.
Which one of the following is true in this situation?
Correct Answer B:
The use of low-molecular-weight heparin allows patients with acute deep vein thrombosis (DVT) to be managed as outpatients. The dosage is 1 mg/kg subcutaneously twice daily. Patient chosen for outpatient care should have good cardiopulmonary reserve, normal renal function, and no risk for excessive bleeding. Oral anti-coagulation with warfarin can be initiated on the first day of treatment after heparin loading is completed.
Monotherapy with warfarin is inappropriate. The incidence of thrombocytopenia with low-molecular-weight heparin is lower than with conventional heparin. The INR should be maintained at 2.0-3.0 in this patient. The 2.5-3.5 range is used for patients with mechanical heart valves. The therapeutic INR should be maintained for 3-6 month in a patient with a first DVT related to travel.
An otherwise healthy 62-year-old male has been hospitalized with community-acquired pneumonia for 2 days. He has remained bedridden. When you see him while making rounds, he mentions that he has noticed increased swelling and pain in his left lower extremity. Lower extremity ultrasonography reveals a deep venous thrombosis (DVT) in his calf. He has no previous history of blood clots.
Which one of the following is the best management of this patient’s DVT?
Without anti-coagulation, patients with an uncomplicated calf deep vein thrombosis (DVT) have a significant risk of further clot extension, acute pulmonary embolus, or recurrence of the thrombus. They are also at risk for late complications such as the post-thrombotic syndrome or chronic thromboembolic hypertension. For this reason, monitoring a DVT by repeat ultrasonography is not a good option unless there are contraindications to anti-coagulation, such as recent surgery, hemorrhagic stroke, active bleeding, or heparin-induced thrombocytopenia.
The recommended treatment for DVT is heparin (intravenous unfractionated or subcutaneous low molecular weight) followed by oral anti-coagulation with warfarin once adequate anti-coagulation is achieved. For a first episode of DVT due to an idiopathic cause or transient risk factor, such as short-term immobilization, the recommended length of treatment is 3-6 months. The benefit-to-risk ratio declines after 6 months unless the patient has a recurrent DVT or a known chronic risk factor, such as a thrombophilic condition or cancer.
Thrombolytic therapy with intravenous tissue plasminogen activator (tPA), urokinase, or streptokinase typically is reserved for patients with life-threatening pulmonary embolism. Inferior vena cava filters are used in patients who have a contraindication to anticoagulant therapy, recurrent venous thromboembolism despite adequate anti-coagulation, or such limited pulmonary vascular reserve that they may not survive additional thromboemboli.
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