March 2017
Definitive Care
Chest Pain3 Chapters
- 1
Introduction
28:38 - 2
Definitive Care
32:27 - 3
Summary
34:27
When it comes to the sickest patients, those with STEMI in need of urgent revascularization or those with a surgical emergency such as a dissection of the aortic arch, a good system that gets identifies these patients and gets them where they need to go quickly is essential. Most patients who present with chest pain are actually not that sick and many can be safely discharged from the ED. It is equally important that systems be in place to manage this larger group of patients.
Ian L. - March 15, 2017 4:39 PM
The 5cm angiocath for needle decompression at the second intercostal space for Tension Pneumothorax has a 38% Failure Rate because of Chest Wall Thickness in the age of bulky people .
Decompression has a 13% failure rate at 4th/5th intercostal space at the anterior axillary line .The Chest Wall thickness in a study by LaanDV et al in Injury April 2016 was 42.79mm 95%CI 38.78- 46.81 for the 2nd Intercostal Space Mid axillary line compared to 34.33mm 95% CI 28.2 -40.7 for the Anterior Axillary line .
Professor Fitzgerald of Trauma at Alfred advocates actually Venting at This Anatomical Area for many adults in a lecture at the Alfred 2015 .
What is the view of the Panel ?
Jess Mason - March 15, 2017 6:01 PM
My opinion is that if the patient is not obese it is reasonable to try needle decompression and the best anatomical location is the ANTERIOR AXILLARY LINE at the 4th to 5th intercostal space, which has the smallest distance for the needle to travel in most patients. If this doesn't work, or if the patient is large, you can always do a finger thoracostomy to decompress the chest followed by a chest tube. Here is a systematic review and meta-analysis on the subject:
Laan DV, Vu TD, Thiels CA, Pandian TK, Schiller HJ, Murad MH, Aho JM. Chest wall thickness and decompression failure: A systematic review and meta-analysis comparing anatomic locations in needle thoracostomy. Injury. 2016 Apr 30;47(4):797-804.
Ian L. - March 15, 2017 4:48 PM
Regarding the prodrome pain of Herpes Zoster I treated a 70 year old lady with antiviral three days into her prodrome and she did not get a rash .
Serology was performed for Hzoster Antibody IGG and IGM when I started the antiviral treatment for ten days and after .
The Hzoster IGM converted from negative to positive .
The pain dissipated there was no rash and no post herpetic neuralgia .
This could be a worthwhile approach with advanced serology :Treating a Prodrome .
What is the view of the Panel .
Jess Mason - March 15, 2017 6:15 PM
Here's a Cochrane Library review of antivirals and post-herpetic neuralgia -- though it does not specifically address your question about preventing the rash. Their conclusion was no significant difference when compared to placebo at 4 months, but some small improvement in pain at 4 weeks.
Chen N, Li Q, Yang J, Zhou M, Zhou D, He L. Antiviral treatment for preventing postherpetic neuralgia. The Cochrane Library. 2014 Jan 1.
Robert E. - March 23, 2017 4:09 AM
With incarcerated diaphragmatic hernia, would it not be best to go ahead and and scan through the abdomen as well, in particular if giving IV contrast on the chest CT? If there is a diaphragmatic hernia, the liklihood of the pt having other intra abominal pathology is likely increased as well, i.e. Bowel obstruction. Thoughts?
Jess Mason - March 24, 2017 7:27 PM
That is a good point and makes sense to me if that is what you are suspecting.
Waqas A. - March 31, 2019 11:36 AM
P for pleuritis!