[vc_row row_type=”row” use_row_as_full_screen_section=”no” type=”full_width” oblique_section=”no” text_align=”left” css_animation=””][vc_column][ultimate_heading main_heading=”Candidate brief” main_heading_color=”#000000″ sub_heading_color=”#000000″ main_heading_style=”font-weight:bold;” main_heading_font_size=”desktop:36px;”]
“This patient is under the care of respiratory outpatients on account of shortness of breath on exertion. Please examine their respiratory system and discuss your findings with the examiners.”
[/ultimate_heading][vc_empty_space image_repeat=”no-repeat”][vc_video link=”https://vimeo.com/138191700″][vc_empty_space image_repeat=”no-repeat”][vc_row_inner row_type=”row” type=”full_width” use_row_as_full_screen_section_slide=”no” text_align=”left” css_animation=””][vc_column_inner width=”1/4″][stat_counter icon_size=”32″ counter_title=”Station Time” counter_value=”20″ counter_suffix=” minutes” speed=”3″][/vc_column_inner][vc_column_inner width=”1/4″][stat_counter icon_size=”32″ counter_title=”Time for this encounter” counter_value=”10″ counter_suffix=” minutes” speed=”3″][/vc_column_inner][vc_column_inner width=”1/4″][stat_counter icon_size=”32″ counter_title=”Maximum time to examine your patient” counter_value=”6″ counter_suffix=” minutes” speed=”3″][/vc_column_inner][vc_column_inner width=”1/4″][stat_counter icon_size=”32″ counter_title=”Minimum time for discussion and questions” counter_value=”4″ counter_suffix=” minutes” speed=”3″][/vc_column_inner][/vc_row_inner][vc_empty_space image_repeat=”no-repeat”][/vc_column][/vc_row][vc_row row_type=”row” use_row_as_full_screen_section=”no” type=”full_width” oblique_section=”no” text_align=”left” css_animation=””][vc_column][vc_accordion style=”accordion”][vc_accordion_tab title=”Common examiner questions”][vc_column_text]Common examiner questions include the following:
- What do you think this patient has?
- How would you like to investigate this patient next?
- What do you think the underlying cause of this patient’s signs is?
[/vc_column_text][/vc_accordion_tab][vc_accordion_tab title=”Diagnosis and clinical signs”][vc_column_text]This patient has had a previous left lobectomy. The clinical signs demonstrated in this video are:
- A left thoracotomy scar;
- Otherwise normal breath sounds throughout the left hemithorax.
A thoracotomy is any surgery involving incisions into the pleural space. It is done in both emergency procedures as well as radical planned procedures.
Thoracotomy procedures involve opening the chest cavity and will involve cutting through the ribs to expose a significant part of the chest to operate. The median sternotomy allows surgeons access to the anterior chest organs. The anterolateral thoracotomy is used in emergency cardiac massage for the management of traumatic cardiac arrest. The posterolateral thoracotomy is used for the resection of posterior lobes, as well as access to the posterior organs such as the dorsal aorta for aortic stenosis or control of bleeding, and the esophagus. The patient will often have to be under general anesthesia unless already unconscious, and will have to be put on a ventilator.
Indications and Contraindications
Emergency thoracotomies are best used in the cases of penetrating chest injuries or cardiac injuries. Thoracotomies are indicated for cases of traumatic internal hemorrhaging, cardiac tamponade, and other immediate problems resulting in hypoperfusion of the rest of the body (Sherren et al, 2013). It may also be used for internal cardiac massage and the prevention of air embolism.
For non-emergency chest procedures involving smaller lesions, such as excision of lung cancer, biopsy, pulmonary decortication, and other lung-related surgeries, consider using video-assisted thoracoscopic surgery (VATS) if the situation allows for it. VATS applications are increasing, and what may have only been possible with a thoracotomy may now be possible with VATS.
Emergency thoracotomies are futile if CPR (cardiopulmonary resuscitation) has been given for 10 minutes after blunt trauma, or 15 minutes after penetrating trauma, pre-hospital, with no response, or if there is no pericardial tamponade but asystole is present (Moore et al, 2011). However, data from Khorsandi et al (2012) suggest that outcomes are worse when thoracotomies are performed on blunt chest trauma patients.
Pneumothorax is the most common post-operative problem of thoracotomy. Other possible problems are air leaks, infection, and bleeding. Respiratory failure can be due to severe dyspnoea from the pain of breathing, or from the failure of oxygen perfusion of the blood in the lung. Atelectasis may also be present, as well as pneumonia, pulmonary embolism, pulmonary oedema, and asthma attacks (Leo et al, 2006).
Khorsandi, M., Skouras, C, & Shah, R. (2012). Is there any role for rescuscitative emergency department thoracotomy in blunt trauma? Interact Cardiovasc Thorac Surg. 2013 Apr; 16(4): 509–516. Published online 2012 Dec 28. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3598040/ on 08 Dec 2015.
Leo, F., Venissac, N., Pop, D., Anziani, M., Leon, M. E., and Mouroux, J. (2006). Anticipating pulmonary complications after thoracotomy: the FLAM Score. J Cardiothorac Surg. 2006; 1: 34. Published online 2006 Oct 6. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1609165/ on 08 Dec 2015.
Moore EE, Knudson MM, Burlew CC, et al; WTA Study Group. Defining the limits of resuscitative emergency department thoracotomy: a contemporary Western Trauma Association perspective. J Trauma. 2011 Feb;70(2):334-9. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/21307731 on 08 Dec 2015.
Sherren, P. B., Reid, C., Habig, K., and Burns, B. J. (2013). Algorithm for the resuscitation of traumatic cardiac arrest patients in a physician-staffed helicopter emergency medical service. Crit Care. 2013; 17(2): 308. Published online 2013 Mar 12. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3672499/ on 08 Dec 2015.
[/vc_column_text][/vc_accordion_tab][vc_accordion_tab title=”Specimen case presentation”][vc_column_text]”This patient has had a previous left lobectomy. They have a left thoracotomy scar and largely normal percussion and breath sounds throughout both lung fields. It is not possible to determine clinically why the operation was undertaken but possibilities include cancer, localised bronchiectasis or perhaps lung volume reduction surgery. I would like to investigate further with some routine venous bloods, a chest x-ray and depending on the patient’s history a CT scan of the chest.”[/vc_column_text][/vc_accordion_tab][/vc_accordion][/vc_column][/vc_row]