Aashi
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A 72-year-old smoker is admitted to the hospital for COPD exacerbation. Admission vitals are respirations 18/min, with a blood pressure of 180/100 mm Hg, and an oxygen saturation of 91%. He is started on nebulized albuterol and ipratropium bromide, as well as prednisolone intravenously. Admission chest radiograph reveals flattened hemidiaphragms, increased retrosternal clear space, and hyperlucent lungs. Given a suspicion of pulmonary embolus, a ventilation perfusion scan is performed demonstrating nonsegmental perfusion defects of the left upper lobe, with a small left lung and a complete absence of perfusion and ventilation of the entire right lung. The patient becomes acutely short of breath in the nuclear medicine department. His respirations are 30/min with otherwise normal vital signs. After supplemental oxygen (4 L/min by nasal cannula) and nebulizers are administered, the respirations become 29/min, with a blood pressure of 80/40 mmHg, and an oxygen saturation of 82%. A repeat chest radiograph is pending. The most appropriate management is to
A. administer heparin, intravenously
B. insert a chest tube on the left side
C. insert a chest tube on the right side
D. obtain a surgical consult for emergent lung volume reduction surgery
E. send him for coronary artery catheterization
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| prathapdoctor
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C insert a chest tube in rt lung.
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| Guptashutosh
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``complete absence of perfusion and ventilation of the entire right lung`` = dat means he has ruptured a bullae and now has collapsed lung with tension pneumothX
and possibly pul ebbolus in the left thX ``ventilation perfusion scan is performed demonstrating nonsegmental perfusion defects of the left upper lobe, with a small left lung ``
So emergency here is to insert a chst tube in the Right side
good luck
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| Aashi
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ANS IS -->C. --> CHEST TUBE IN RIGHT LUNG..
The patient is exhibiting clinical signs of a tension pneumothorax, including pulmonary and cardiac failure.
The ventilation perfusion scan demonstrates lack of ventilation and perfusion of the right lung, which is consistent with a pneumothorax.
A tension pneumothorax must be suspected given the diminished size of the left lung. A tension pneumothorax is a unilateral pneumothorax that becomes loculated by a one-way valve mechanism and compromises the contralateral lung and the venous return to the chest. Diagnosis is made by the lack of ipsilateral lung sounds due to cardiopulmonary collapse or chest radiograph. Treatment is immediate chest tube insertion to relieve the pressure in the right hemithorax.
The ventilation perfusion scan is consistent with a pneumothorax of the right lung with signs of tension, given the small left lung. The ventilation perfusion mismatches of the left lung apex are consistent with bullous disease, which is common in patients with COPD. A pulmonary embolus creates ventilation perfusion mismatches on the ventilation perfusion scan. Heparin would be an appropriate treatment if the ventilation perfusion scan was positive for pulmonary embolus (choice A).
The chest tube must be ipsilateral to the tension pneumothorax, not on the left side (choice B).
Volume reduction surgery (choice D) is a controversial method for reducing lung volumes in patients with emphysema. It is an elective procedure and is inappropriate for the management of tension pneumothorax.
The patient's low blood pressure is due to the effect of the tension pneumothorax on preload, not due to intrinsic coronary artery disease as seen in a cardiac catheterization (choice E)
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"Obstacles are those frightful things you see when you take your EYES off your goal."
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