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CCRN Pneumothorax Overview

Pneumothorax

A pneumothorax is an abnormal collection of air or gas in the pleural space that causes an uncoupling of the lung from the chest wall. Like pleural effusion (liquid buildup in that space), pneumothorax may interfere with normal breathing. It is often called collapsed lung, although that term may also refer to atelectasis. One or both lungs may be affected. A primary pneumothorax is one that occurs spontaneously without an apparent cause and in the absence of significant lung disease, while a secondary pneumothorax occurs in the presence of existing lung pathology. Pneumothoraces can be caused by physical trauma to the chest (including blast injury), or as a complication of medical or surgical intervention; in this case it is referred to as a traumatic pneumothorax. In a minority of cases of both spontaneous or traumatic pneumothorax, the amount of air in the chest increases markedly when a one-way valve is formed by an area of damaged tissue, leading to a tension pneumothorax. This condition is a medical emergency that can cause steadily worsening oxygen shortage and low blood pressure. Unless reversed by effective treatment, these sequelae can progress and cause death.

Signs and Symptoms

• • Chest pain
  • Shortness of breath
  • Decreased or absent breast sounds on the affected side
  • Agitation
  • Tachycardia

Causes

A pneumothorax can be caused by:

• Chest injury. Any blunt or penetrating injury to your chest can cause lung collapse. Some injuries may happen during physical assaults or car crashes, while others may inadvertently occur during medical procedures that involve the insertion of a needle into the chest.
• Lung disease. Damaged lung tissue is more likely to collapse. Lung damage can be caused by many types of underlying diseases, including chronic obstructive pulmonary disease (COPD), cystic fibrosis and pneumonia.
• Ruptured air blisters. Small air blisters (blebs) can develop on the top of your lung. These blebs sometimes burst — allowing air to leak into the space that surrounds the lungs.
• Mechanical ventilation. A severe type of pneumothorax can occur in people who need mechanical assistance to breathe. The ventilator can create an imbalance of air pressure within the chest. The lung may collapse completely.

Risk Factors

Risk factors for a pneumothorax include:

• Sex. In general, men are far more likely to have a pneumothorax than are women.
• Smoking. The risk increases with the length of time and the number of cigarettes smoked, even without emphysema.
• Age. The type of pneumothorax caused by ruptured air blisters is most likely to occur in people between 20 and 40 years old, especially if the person is a very tall and underweight.
• Genetics. Certain types of pneumothorax appear to run in families.
• Lung disease. Having an underlying lung disease — especially chronic obstructive pulmonary disease (COPD) — makes a collapsed lung more likely.
• Mechanical ventilation. People who need mechanical ventilation to assist their breathing are at higher risk of pneumothorax.
• Previous pneumothorax. Anyone who has had one pneumothorax is at increased risk of another, usually within one to two years of the first.

Diagnosis

• A pneumothorax is diagnosed by a combination of signs and symptoms, chest X-ray, and CT scan of the chest

Treatment

• Chest tube insertion on the affected side
• Possible needle decompression
• Oxygen
• Pain medications
• Monitor VS
• ICU admission if severely compromised

 

CCRN Cardiac Tamponade

Cardiac tamponade, also known as pericardial tamponade, is a type of pericardial effusion in which fluid, pus, blood, clots, or gas accumulates in the pericardium (the sac in which the heart is enclosed), resulting in slow or rapid compression of the heart. Cardiac tamponade is pressure on the heart muscle which occurs when the pericardial space fills up with fluid faster than the pericardial sac can stretch. If the amount of fluid increases slowly (such as in hypothyroidism) the pericardial sac can expand to contain a liter or more of fluid prior to tamponade occurring. If the fluid effusion occurs rapidly (as may occur after trauma or myocardial rupture) as little as 100 mL can cause tamponade. Myocardial rupture is a somewhat uncommon cause of pericardial tamponade. It typically happens in the subacute setting after a heart attack, in which the infarcted muscle of the heart thins out and tears. Myocardial rupture is more likely to happen in elderly individuals without any previous cardiac history who suffer from their first heart attack and are not revascularized either with thrombolytic therapy or with percutaneous coronary intervention or with coronary artery bypass graft surgery. One of the most common settings for cardiac tamponade is in the first 24 to 48 hours after heart surgery. After heart surgery, chest tubes are placed to drain blood. These chest tubes, however, are prone to clot formation. When a chest tube becomes occluded or clogged, the blood that should be drained can accumulate around the heart, leading to tamponade. Nurses will frequently clear clots from the tubes, but even with these efforts chest tubes can become clogged.

Signs and Symptoms

• anxiety and restlessness
• low blood pressure
• weakness
• chest pain radiating to your neck, shoulders, or back
• trouble breathing or taking deep breaths
• rapid breathing
• discomfort that’s relieved by sitting or leaning forward
• fainting, dizziness, and loss of consciousness

Causes

• gunshot or stab wounds
• blunt trauma to the chest from a car or industrial accident
• accidental perforation after cardiac catheterization, angiography, or insertion of a pacemaker
• punctures made during placement of a central line, which is a type of catheter that administers fluids or medications
• cancer that has spread to the pericardial sac, such as breast or lung cancer
• a ruptured aortic aneurysm
• pericarditis, an inflammation of the pericardium
• lupus, an inflammatory disease in which the immune system mistakenly attacks healthy tissues
• high levels of radiation to the chest
• hypothyroidism, which increases the risk for heart disease
• a heart attack
• kidney failure
• infections that affect the heart

Complications

• Heart failure
• Pulmonary edema
• Shock
• Death

Treatment

• Pericardiocentesis
• Pericardial Window
• Oxygen
• Thoracotomy
• Chest tubes

 

CCRN Aortic Aneurysm Overview

Thoracic Aortic Aneurysm

A thoracic aortic aneurysm is an aortic aneurysm that presents primarily in the thorax.  A thoracic aortic aneurysm is the "ballooning" of the upper aspect of the aorta, above the diaphragm. Untreated or unrecognized they can be fatal due to dissection or "popping" of the aneurysm leading to nearly instant death. Thoracic aneurysms are less common than an abdominal aortic aneurysm.  However, a syphilitic aneurysm is more likely to be a thoracic aortic aneurysm than an abdominal aortic aneurysm. A thoracic aortic aneurysm may also be called thoracic aneurysm and aortic dissection (TAAD) because an aneurysm can lead to a tear in the artery wall (dissection) that can cause life-threatening bleeding. Small and slow-growing thoracic aortic aneurysms may not ever rupture, but large, fast-growing aneurysms may rupture.  Depending on the size and growth rate of your thoracic aortic aneurysm, treatment may vary from watchful waiting to emergency surgery. Ideally, surgery for a thoracic aortic aneurysm can be planned if necessary.

Signs and Symptoms

Thoracic aortic aneurysms often grow slowly and usually without symptoms, making them difficult to detect. Some aneurysms will never rupture. Many start small and stay small, although many expand over time. How quickly an aortic aneurysm may grow is difficult to predict. As a thoracic aortic aneurysm grows, some people may notice:

• Tenderness or pain in the chest
• Back pain
• Hoarseness
• Cough
• Shortness of breath

Aneurysms can develop anywhere along the aorta, which runs from your heart through your abdomen. When they occur in the upper part of the aorta, they are called thoracic aortic aneurysms. Aneurysms can occur anywhere in the thoracic aorta, including the ascending aorta near the heart, the aortic arch in the curve of the thoracic aorta and the descending aorta in the lower part of the thoracic aorta. Aneurysms that form in the lower part of your aorta — called abdominal aortic aneurysms — are more common than thoracic aortic aneurysms. An aneurysm can also occur in between the upper and lower parts of your aorta. This type of aneurysm is called a thoracoabdominal aneurysm.

Causes

Factors that can contribute to an aneurysm's development include:

• Hardening of the arteries (atherosclerosis). As plaque builds up on your artery walls, they become less flexible, and the additional pressure can cause them to weaken and bulge. High blood pressure and high cholesterol are risk factors for hardening of the arteries. This is more common in older people.
• Genetic conditions. Younger people with an ascending aortic aneurysm often have a genetic cause. People who are born with Marfan syndrome, a genetic condition that affects the connective tissue in the body, are particularly at risk of a thoracic aortic aneurysm. Those with Marfan syndrome may have a weakness in the aortic wall that makes them more susceptible to aneurysm. People with Marfan syndrome often have distinct physical traits, including tall stature, very long arms, a deformed breastbone and eye problems.Besides Marfan syndrome, other related disorders, such as Ehlers-Danlos and Loeys-Dietz syndromes, can contribute to a thoracic aortic aneurysm. Ehlers-Danlos syndrome causes your skin, joints and connective tissue to be fragile and makes your skin stretch easily.
• Other medical conditions. Inflammatory conditions, such as giant cell arteritis and Takayasu arteritis, may cause thoracic aortic aneurysms.
• Problems with your heart's aortic valve. Sometimes people who have problems with the valve that blood flows through as it leaves your heart (aortic valve) have an increased risk of thoracic aortic aneurysm. This is mainly true for people who were born with a bicuspid aortic valve, meaning the aortic valve has only two leaflets instead of three.
• Untreated infection. Though it is a rare cause of thoracic aortic aneurysm, it's possible to develop this condition if you've had an untreated infection, such as syphilis or salmonella.
• Traumatic injury. Rarely, some people who are injured in falls or motor vehicle crashes develop thoracic aortic aneurysms.

Risk Factors

Thoracic aortic aneurysm risk factors include:

• Age. Thoracic aortic aneurysms occur most often in people age 65 and older.
• Tobacco use. Tobacco use is a strong risk factor for the development of an aortic aneurysm.
• High blood pressure. Increased blood pressure damages the blood vessels in the body, raising your chances of developing an aneurysm.
• Buildup of plaques in your arteries (atherosclerosis). The buildup of fat and other substances that can damage the lining of a blood vessel (atherosclerosis) increases your risk of an aneurysm. This is a more common risk in older people.
• Family history. People who have a family history of aortic aneurysm are at increased risk of having one. People who have a family history of aneurysms tend to develop aneurysms at a younger age and are at higher risk of rupture. This is a primary risk factor in younger people.
• Marfan syndrome and related disorders. If you have Marfan syndrome or related disorders such as Loeys-Dietz syndrome or Ehlers-Danlos syndrome, you have a significantly higher risk of a thoracic aortic aneurysm.

Diagnosis

• Chest X-ray
• Echocardiogram
• CT scan of chest
• Magnetic Resonance Angiography (MRA)

Treatments

The size of the aneurysm, presence and severity of symptoms, and the risk of surgery help determine the treatment approach.

REGULAR MONITORING is standard treatment for smaller aneurysms that do not require surgery. Plan on visiting your vascular surgeon regularly—usually once a year or every 6 months, depending on the size of the aneurysm—for a computed tomography (CT) scan or MRI to check the status and growth of the aneurysm. CONVENTIONAL SURGERY, a procedure called open thoracic aortic aneurysm repair or TAA, is done under a general anesthetic.

• Through an incision along the side of the chest, a vascular surgeon uses special surgical tools to stop blood flow in the aorta above and below the aneurysm.
• The section of the aorta with the aneurysm is replaced with an artificial graft.
• The graft is sewn in place with fine stitches, and the incision is closed.
• Most patients spend some time in the intensive care unit after surgery, and stay in the hospital 7-10 days.

ENDOVASCULAR TREATMENT is sometimes used and represents a less invasive approach. Thoracic aortic endograft repair (TEVAR) treats the aneurysm with a small device placed inside the aorta through a small incision or through puncture in the groin.