CHEST TUBE
RADIOTHERAPY MARKS Vital points on examination:
Of the underlying disease:
o Cachexia,
o masectomy scar/ wide excision scar suggest breast cancer o obvious skin cancer,
o clubbing & other signs of chest disease suggest lung cancer o suprapubic mass suggest pelvic tumour
o neck swellings with cranial nerve palsies head and neck tumour
of the radiotherapy:
o site of radiation
o shape: usually well defined borders o features of active RT:
Indian ink marks, skin markings
Erythema, desquamation o Features of previous RT:
Telangiectasia, hyperpigmentation
Complications of radiotherapy:
o Depends of site
o Look for future cancers:
Haematogenous malignancy
Thyroid cancers
Breast cancers
Background information
High energy X-rays interact with tissue to release electrons that cause local damage to DNA in adjacent cells via oxygen dependent mechanism.
o Damage is usually irreparable, and normal cells have greater ability to repopulate than tumour cells in this setting
o If reparable, manifests as chromosomal abnormalities
Radiotherapy affects cells with:
o Rapid turnover: Skin (epidermal layers), small intestine, bone marrow stem cells
o Limited replicative ability: spinal cord, gonads
Complications:
o Early:
General: malaise, fatigue, LOA, N/V
Skin changes & temporary hair loss
Bone marrow suppresion, esp. if to long bone and pelvis
GI: diarrhea o Late:
Skin changes
Heart: IHD
Lung: pneumonitis, pulmonary fibrosis
Bld vssl: radiation arteritis, esp to carotids necrosis, distal ischaemia and vssl rupture
CNS: spinal cord myelopathy
Uro: bladder fibrosis, Renal impairment (depletion of tubular cells)
Abdo: IO 2o to strictures & adhesions,
Genital: infertility
Endocrine: hypothyroidism
Eye: cataracts
Increase incidence of future cancers:
Haematogenous malignancy, e.g. leukemia
Solid tumours: Thyroid cancers
Breast cancers
Minimalising of side effects of radiotherapy:
o Lead shields to eyes, gonads and thyroid
o Dose fractionation (to allow recovery of normal cells) o Prior chemotherapy (increase sensitivity of tumour cells) o Regional hypothermia
o Radiolabelled antibody to deliver local radiation to tumour
ASCITES
Vital signs on examination:
o Abdominal distension
o Flank dullness shifting dullness fluid thrill
o Peripheral stigmata of chronic liver disease and portal HPT
o Other signs of fluid overload: LL, sacral oedema, bibasal crepitations o Signs of malignancy
Background information
Causes of ascites:
Transudate (<30g/L protein) Exudative (>30g/L) Cardiac: CCF, RHF, TR, constrictive
pericarditis
Cirrhosis
Abdo: CLD Malignancy
Renal: ESRF, nephrotic syndrome Infective causes: TB GIT: protein losing enteropathy Chylous ascites
Role of peritoneal tap:
o diagnostic and therapeutic
Send fluid for FEME, protein, microbiology, cytology
Relieve of discomfort & diaphragm splinting from distension o Indications:
Failed medical treatment
symptomatic
o perform under aseptic technique, LA, US guidance
may insert a pigtail catheter via seldinger technique
open drain into stoma bag
Treatment of ascites:
o Conservative: low salt diet, diuresis o Peritoneal tap
o Surgical: shunt surgery (TIPSS, peritoneovenous shunt [silastic catheter], Denver shunt when with a subcutaneous pump]
SHOCK
Definition – inadequate tissue and organ perfusion leading to a hypoperfusion state &
eventual cellular hypoxia and its attendant sequelae.
S/S: Hypotension, urine output, tachycardia, diaphoresis, AMS
Types of Shock
‗White‘ shock ‗Red‘ shock
Types Hypovolaemic Cardiogenic Neurogenic Septic Anaphylactic Causes Haemorrhage
Burns Ruptured ectopic pregnancy Severe GE Acute pancreatitis
AMI
Dysrhythmia
Spinal injury
Infxns
S/S Pallor Cold clammy skin
peri vas
Pallor Cold clammy skin
peri vas
Warm skin N/ heart rate Neuro deficit
Fever, rigors Warm skin
Fever, rigors Warm skin
Invxs Hct (late) Cardiac enzymes ECG
FBC Bld C/S
Also, Obstructive Shock due to tension pneumothorax, cardiac tamponade or pulmonary embolism
Management General Mx
Airway Maintain airway – consider intubation if necessary Breathing 100% O2 via non-rebreather mask
Circulation 2 large bore (14-16G) cannulae
Inotropic support
o IV dopamine 5-10g/kg/min
o IV dobutamine 5-10g/kg/min (esp for cardiogenic shock)
o IV norepinephrine 5-20g/kg/min (esp for septic shock)
Monitoring Pulse oximetry
ECG
BP
Heart rate
Urine output – catheterize patient
Hypovolaemic Shock
Invxs FBC - Hct in acute alcoholic binge due to diuresis. Hct is an Inaccurate marker of bld loss acutely.
GXM 6 units
U/E/Cr
Troponin T & Cardiac enzymes
Coagulation profile with DIVC screen (PT/PTT, pltlet, D-dimer)
ABG – metab acidosis, lactate, base deficits are poor Px factors
UPT - ?ectopic pregnancy? Ask for LMP
Examine abdomen for pulsatile AAA Fluid Rx 1 L crystalloid fast infusion w/in 1 hr
Assess response
Subsequent colloid or whole blood infusion
CVP line Used to guide fluid Rx, esp in CCF patients
Cardiogenic Shock ECG
Trop T & cardiac enzymes
Manage accordingly – refer acute coronary syndrome & ACLS notes
Neurogenic Shock
Hx/PE Trauma – site, mechanism, force
Neuro exam, DRE – document initial neurological deficits Immobilize Immobilize spine in neutral position
Invxs C-spine X-ray (AP & lat) – ensure visualization up to C7/T1 junction
Swimmer‘s view (visualize C7/T1 jn) & open mouth view (visualize C1/2 injury)
Thoracic & lumbar spine X-ray (AP & lat)
CT scan
MRI later
Fluid Rx Titrate fluid resus with urine output
vasopressors if BP does not respond to fluid challenge
IV methyl prednisolone
30 mg/kg over 15mins, followed by 5.4mg/kg/h for nxt 23 hrs
Indications – non-penetrating spinal cord injury & w/in 8 hrs of injury
Contraindications o <13YO o pregnancy
o mild injury of the cauda equina / nerve root o abdominal trauma present
o major life-threatening morbidity Disposition Refer Ortho / NeuroSx
Obstructive Shock Tension
Pneumothorax
Decompression: insert 14G cannula over 2nd intercostals space in mid-clav. Line
Cardiac tamponade
IV fluid bolus 500ml N/S
IV dopamine infusion 5g/kg/min
Prepare for pericardiocentesis Pul Embolism Invx
FBC
o widened alveolo-arterial P02 gradient (AaPO2
>20mmHg)
ECG (may be normal)
o non-specific ST depression & T wave inversion o Sinus tachycardia
o Right heart strain
Right axis deviation
Transient RBBB
T wave inversion in V1-3
P pulmonale
S1Q3T3
o Exclude DDxes – MI, pericarditis
CXR (may be normal)
o Westermark sign – oligaemic lung fields o Pul infarcts – wedge shape opacities w apex
pointing towards the hilum o Atelectasis
o Pleural effusions o Raised diaphragm o Consolidation o ‗Plump‘ pul. arteries
o Exclude DDxes – pneumothorax, pneumonia, L heart failure, tumour, rib #, massive pleural effusion, lobar collapse
Spiral CT, Echo, MRI, lung scintigraphy, pulmonary angiogram (gold std)
Rx
Pain relieve – use Opioids with caution
Fluid Rx & inotropic support if haemodynamically unstable
Anticoagulation Rx:
o IV heparin 5000U bolus or SC fraxiparine (0.4ml if <50kg; 0.5ml if 50-65kg; 0.6ml if >65kg) o Convert to Oral warfarin later
Thrombolysis
o Intra pul. arterial urokinase fro 12-24 hrs
Surgical
o Complete IVC ligation or partial caval interruption Septic Shock (SIRS + source of sepsis + shock)
SIRS = 2 of the following present:
o Temp >38 or <36oC o HR > 90bpm
o RR > 20 breaths/min OR PaCO2<32mmHg
o WCC>12000/mm3, <4000/mm3,or >10% immature forms
Hx / PE Identify site of infxn – UTI (indwelling cathether), gallbladder dz, peritonitis, pneumonia, appendicitis, immunocompromised state
Invx FBC - TW
U/E/Cr
DIVC screen – PT/PTT, pltlet, fibrinogen, D-dimer
Bld C/S (2 different sites)
Capillary bld glucose
ABG
CXR – pneumonia, ARDS
ECG
Urine dipstick – UTI
Urine C/S
Fluid Rx Rapid infusion 1-2L crystalloids
CVP line insertion
Inotropic support
if no response to fluid Rx
Noradrenaline (drug of choice) - 1g/kg/min OR
Dopamin 5-20g/kg/min Empirical
Quinolones (ciprofloxacin 200mg)
Immunocompromised w/o obvious source
Anti-pseudomonal ABx (IV ceftazidime 1g) OR
Quinolone
PLUS aminoglycoside (Gentamicin 80mg) Gram-positive (burns, FB /
lines present)
IV cefazolin 2g
IV vancomycin 1g if hx of IVDA, indwelling cath. Or penicillin allergy
Anaerobic source (intra-abdo, biliary, female genital tract, aspiration pneumonia)
IV metronidazole 500mg + ceftriazone 1g + IV gentamicin 80mg
Anaphylactic Shock Definitions
Urticaria – oedematous & pruritic plaques w pale centre & raised edges
Angioedema – oedema of deeper layers of the skin. Non-pruritic. May be a/w numbness & pain
Anaphylaxis – severe systemic allergic rxn to an Ag. Ppt by abrupt release of chemical mediators in a previously sensitized patient
Anaphylactoid rxn – resembles anaphylactic rxn, but due to direct histamine release from mast cells w/o need for prior sensitization
Common causes
Drugs – penicililns & NSAIDS commonest, aspirin, TCM, sulpha drugs
Food – shellfish, egg white, peanuts
Venoms – bees, wasps, hornets
Environment – dust, pollen
Infections – EBV, HBV, coxsackie virus, parasites
Stop Pptant Stop administration of suspected agent / flick out insect stinger with tongue blade
Gastric lavage & activated charcoal if drug was ingested
Airway Prepare for intubation or cricothyroidectomy – ENT/Anaesthesia consult
Fluid Rx 2L Hartman‘s or N/S bolus
Drug Rx Adrenaline Normotensive – 0.01ml/kg (max 0.5ml) 1:1000 dilution SC/IM
Hypotensive – 0.1ml/kg (max 5ml) 1:10,000 dilution IV over 5 mins
Glucagon Indications: failure of adrenaline Rx OR if adrenaline is contraindicated eg IHD, severe HPT, pregnancy, -blocker use
0.5-1.0mg IV/IM. Can be repeated once after 30mins
Antihistamines Diphenhydramine 25mg IM/IV
Chlorpheniramine 10mg IM/IV
Promethazine 25mg IM/IV
Cimetidine For persistent symptoms unresponsive to above Rx
200-400mg IV bolus Nebulised
bronchodilator
for persistent bronchospasm
Salbutamol 2:2 q20-30mins
Corticosteroids Hydrocortisone 200-300mg IV bolus, q 6hr
DGIM – Last updated March 2005
CAUSES of LOWER GIT BLEEDING 1) Colon
Bleeding diverticulosis
Angiodysplasia
Colorectal carcinoma, polyps
Colitis
- Infective (gastroenteritis, diverticulitis, colorectal TB) - Inflammatory (UC & Crohn‘s)
- Ischaemic
2) Ileum: Meckel‘s diverticulum - usually dark red blood 3) Anorectal junction: hemorrhoids
4) Anus: anal fissure
5) Massive Upper GIT bleeding, e.g. bleeding DU
HISTORY (if patient is stable) 1) Nature of bleeding
Haematochezia
- Mixed with or coating stool
- Torrential or drops, any clots? – Brisk upper GI bleed can present as haematochezia
- Bright red (lower) or darker red (higher) - Any mucous
Malaena
- Altered blood, indicates bleeding from upper GIT above ligament of Treitz (duodeno-jejunal junction)
- Ask for history as per UBGIT 2) Aetiological clues
Exclude upper GIT cause
- Any malaena, hematemesis, coffee grounds vomitus
- History of PUD, gastritis, varices, Ca stomach, Mallory-Weiss tear, risk factors for each
Bleeding diverticulosis/angiodysplasia
- Usually torrential bleeding that stops spontaneously; altered clots - History of previous bleeding episodes
Colorectal carcinoma
- Constitutional symptoms: LOW, LOA, fatigue - Change in bowel habits, tenesmus
- Symptoms of anaemia (chronic occult bleed)
- Previous history/family history of GIT or ovarian cancer
Colitis
- Infective: any fever/chills/rigors, night sweats, N/V, diarrhoea, pain, recent travel/contact history, eating seafood, previous TB exposure or infection, BCG vaccination status
- Inflammatory: ask about history of UC or Crohn‘s, joint, liver, eye & skin manifestations
- Ischaemic: ask about atherosclerotic risk factors, previous AMI, stroke
Hemorrhoids
- bleeding to passing motion, blood coating stool, pain - Any mass noticed at anus
- History of constipation, hard stools, low fibre diet, chronic straining, recent pregnancy
Coagulopathy
- Any history of bleeding disorders, easily bleeding, petechiae 3) Complications
Symptoms of anemia (may be only presentation!): SOB, postural giddiness, palpitations, chest pain, ↓ effort tolerance, fatigue, syncope
Symptoms of dehydration & shock: extreme thirst, confusion, pallor, ↓ urine output
May have complication of AMI if old patient with history of IHD PHYSICAL EXAMINATION
1. Vitals:
- HR, supine & postural BP –stable? urine output (if catheter in-situ), - Any fever?
2. General inspection:
- pallor, - confusion?
3. Peripheries:
- signs of dehydration e.g. capillary refill, dry tongue.
- Any supraclavicular lymph nodes?
- Any skin manifestations of inflammatory bowel disease?
- Stigmata of CLD?
4. Abdomen:
- Scars? Any palpable masses 5. DRE:
- any anal fissures or prolapsed hemorrhoids seen, - any masses felt,
- any fresh blood or malaena
6. Offer proctoscopy to look for internal haemorrhoids
ACUTE MANAGEMENT