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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_2693_Библиотеки_им_академика_М_И_Перельмана.pdf
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• Other forms of pure hypoxia produce similar ndings.
• “Cherry red” appearance of lips and skin (a late nding)
C. V. Pollack, Jr. et al.
The cheeks and neck are red in this patient with carbon monoxide poisoning. [Allen
HB. Dermatology terminology [Internet]. London: Springer; 2010. Chapter 8,
Miscellaneous disorders; [cited 2015 Sep 9]; p.171–85. Available from:
springer.com/10.1007/978-1-84882-840-7_8
] Caption from original
http://link.
Signs and symptoms of carbon monoxide poisoning [Knighton J.Nursing management of the burn-injured person. In: Jeschke MG, Kamolz L-P, Shahrokhi S, editors.
Burn care and treatment [Internet]. Vienna: Springer; 2013 [cited 2015 Sep 9].
p.111–47. Available from: http://link.springer.com/10.1007/978-3-7091-1133-8_8]
Caption from original
16 Carbon Monoxide Poisoning
Stages of carbon monoxide poisoning [Dettmeyer RB, Verhoff MA, Schütz
HF.Forensic medicine [Internet]. Berlin, Heidelberg: Springer; 2014. Chapter 30,
Forensic toxicology; [cited 2015 Sep 9]; p.495–542. Available from: http://link.
springer.com/10.1007/978-3-642-38818-7_30] Caption from original
263
Factors That Exclude Diagnosis
The only way to exclude CO toxicity denitively is with an arterial blood gas panel
with co-oximetry.
Ancillary Studies
Laboratory
• Elevated COHb level
• Nonsmokers may have up to 3 %, smokers 10 % to 15 %. Anything above
these levels may be considered CO poisoning.
• In CO poisoning as a result of suicide attempt, a drug screen should also be
obtained.
264
Electrocardiography
• Sinus tachycardia/arrhythmias/myocardial injury
Computed Tomography (CT) ofthebrain
• Hypoattenuation of the globus pallidus and white matter changes
C. V. Pollack, Jr. et al.
16 Carbon Monoxide Poisoning
Four different patients with history of carbon monoxide poisoning. a Noncontrast
head CT shows focal low density in bilateral globus pallidus (arrows). b Transaxial
T2 weighted image shows bilateral symmetric hyperintensity involving globus pallidus (arrows). c DWI shows bilateral pallidal diffusion restriction (arrows). d
Noncontrast head CT shows diffuse anoxic injury (short arrows) in addition to the
basal ganglia hypodensities (long arrow) [Moore MJ, Vagal AS, Strub WM, Leach
JL.Reducing the gray zone: imaging spectrum of hypoperfusion and hypoxic brain
injury in adults. Emerg Radiol. 2010 Mar;17(2):123–30.] Caption from original
265
Special Populations
Age
• Older patients with limited cardiopulmonary reserve may develop clinical
manifestations at lower CoHb levels.
Co-morbidities
• Pregnancy
• The fetus is particularly sensitive to hypoxemia, so both mother and child
are at signicant risk.
• Patients with preexisting lung disease are affected more severely by
CO-induced hypoxemia.
Pediatric Considerations
• Signs and symptoms may be subtle and nonspecic.
• Infants and toddlers may have fussiness and difculty feeding.
• Signs and symptoms in older children are similar to those in adults: headache,
nausea, and vomiting.
• Younger children experience problems earlier in exposure because of of
higher rates of oxygen utilization and minute ventilation.
Pitfalls inDiagnosis
Critical Steps Not toMiss
• Without the patient’s history, CO toxicity may be difcult to diagnosis.
Standard pulse oximetry cannot screen for CO exposure.
266
• All individuals at a re scene and/or with signicant thermal injury should be
evaluated for CO poisoning.
C. V. Pollack, Jr. et al.
Mimics
• Most common misdiagnosis is viral syndrome.
• Very high or very low blood glucose levels may present similarly to CO
toxicity.
Time-Dependent Interventions
• CO poisoning is associated with high morbidity and mortality. In the absence
of exposure history, CO poisoning must be considered in two or more patients
who present with similar symptoms simultaneously.
• Oxygen therapy should be started while COHb tests results are pending.
• Hyperbaric oxygen (HBO) therapy, if available, should be considered, especially in cases of severe exposure and in pregnant patients.
Overall Principles ofTreatment
• 100 % oxygen therapy is the main treatment for CO poisoning.
• HBO is indicated in anyone who experienced unconsciousness, cardiovascular instability or ischemia, persistent mental and/or neurologic decits, or a
COHb level greater than 25 %.
• HBO may help the late neurocognitive outcomes.
• HBO should be considered in pregnant patients with elevated COHb levels.
Disease Course
• Outcomes are difcult to predict, even when the CO level is known. Patients
with cardiac arrest or coma may recover fully after treatment. The mortality
rate in severe CO toxicity is 33 % or higher.
16 Carbon Monoxide Poisoning
267
Related Evidence
Papers of particular interest have been highlighted as:
** Of key importance
Practice Guideline
Wolf SJ, Lavonas EJ, Sloan EP, Jagoda AS; American College of Emergency
Physicians. Clinical policy: critical issues in the management of adult patients presenting to the emergency department with acute carbon monoxide poisoning. Ann Emerg
Med. 2008 Feb;51(2):138-52. https://doi.org/10.1016/j.annemergmed.2007.10.012.
PMID: 18206551. http://www.ncbi.nlm.nih.gov/pubmed/18206551 **
Review
Betterman K, Patel S.Neurologic complications of carbon monoxide intoxication.
Handb Clin Neurol. 2014;120:971-9. https://doi.org/10.1016/B978-0-7020-4087-
0.00064-4. PMID: 24365364. http://www.ncbi.nlm.nih.gov/pubmed/24365364 **
Kurt F, Bektaú Ö, Kalkan G, Öncel MY, Yakut HI, Kocabaú CN.Does age affect pre-
senting symptoms in children with carbon monoxide poisoning? Pediatr Emerg
Care. 2013 Aug;29(8):916-21. https://doi.org/10.1097/PEC.0b013e31829ec22b.
PubMed PMID: 23903672. http://www.ncbi.nlm.nih.gov/pubmed/23903672
Huzar TF, George T, Cross JM.Carbon monoxide and cyanide toxicity: etiology,
pathophysiology and treatment in inhalation injury. Expert Rev Respir Med.
2013 Apr;7(2):159-70. https://doi.org/10.1586/ers.13.9. PMID: 23547992.
http://www.ncbi.nlm.nih.gov/pubmed/23547992 **
Guzman JA.Carbon monoxide poisoning. Crit Care Clin. 2012 Oct;28(4):537- 48.
https://doi.org/10.1016/j.ccc.2012.07.007. PMID: 22998990. http://www.ncbi.
nlm.nih.gov/pubmed/22998990 **
Iqbal S, Clower JH, Hernandez SA, Damon SA, Yip FY.A review of disaster- related
carbon monoxide poisoning: surveillance, epidemiology, and opportunities for
prevention. Am J Public Health. 2012 Oct;102(10):1957-63. PMID: 22897556.
http://www.ncbi.nlm.nih.gov/pubmed/22897556 **
Hampson NB, Piantadosi CA, Thom SR, Weaver LK.Practice recommendations in the
diagnosis, management, and prevention of carbon monoxide poisoning. Am J Respir
Crit Care Med. 2012 Dec 1;186(11):1095-101. https://doi.org/10.1164/rccm.201207-
1284CI. PMID: 23087025. http://www.ncbi.nlm.nih.gov/pubmed/23087025 **
Buckley NA, Juurlink DN, Isbister G, Bennett MH, Lavonas EJ.Hyperbaric oxygen
for carbon monoxide poisoning. Cochrane Database Syst Rev. 2011 Apr
268
C. V. Pollack, Jr. et al.
13;(4):CD002041. https://doi.org/10.1002/14651858.CD002041.pub3. PMID:
21491385. http://www.ncbi.nlm.nih.gov/pubmed/21491385 **
Smollin C, Olson K.Carbon monoxide poisoning (acute). Clin Evid (Online). 2010
Oct 12;2010. pii: 2103. PMID: 21418677.
http://www.ncbi.nlm.nih.gov/
pubmed/21418677 **
Weaver LK.Clinical practice. Carbon monoxide poisoning. N Engl J Med. 2009
Mar 19;360(12):1217-25. https://doi.org/10.1056/NEJMcp0808891. PMID:
19297574. http://www.ncbi.nlm.nih.gov/pubmed/19297574 **
Cho CH, Chiu NC, Ho CS, Peng CC.Carbon monoxide poisoning in children. Pediatr
Neonatol. 2008 Aug;49(4):121-5. https://doi.org/10.1016/S1875-9572(08)60026-
1. PMID: 19054917. http://www.ncbi.nlm.nih.gov/pubmed/19054917 **
Cohort Study
Kurt F, Bektaú Ö, Kalkan G, Öncel MY, Yakut HI, Kocabaú CN.Does age affect pre-
senting symptoms in children with carbon monoxide poisoning? Pediatr Emerg
Care. 2013 Aug;29(8):916-21. https://doi.org/10.1097/PEC.0b013e31829ec22b.
PMID: 23903672. http://www.ncbi.nlm.nih.gov/pubmed/23903672
Use PubMed Clinical Queries to nd the most recent evidence. Use this search strategy:
“Carbon Monoxide Poisoning”[Mesh] OR “carbon monoxide poisoning”
Chapter 17
Chest Neoplasms
ChristopherJ.Rees, CharlesV.Pollack,Jr., andVictoriaG.Riese
Name andSynonyms
Chest Neoplasms
Incidence/Epidemiology
• The incidence of chest neoplasm varies widely by tumor type.
• Chest neoplasms are of much higher incidence in adults.
• Over large populations, chest neoplasia incidence follows tobacco abuse patterns and therefore is more common in older males.
• In women, lung and breast tumors are most common.
• Metastases of colon cancer to the thorax are not uncommon.
Differential Diagnosis
• Many neoplasms may present as chest masses.
• They may be either benign or malignant lesions.
C. J. Rees
Emergency Department, Pennsylvania Hospital, Philadelphia, PA, USA
C. V. Pollack,
Department of Emergency Medicine, Thomas Jefferson University,
Philadelphia, PA, USA
V. G. Riese
Librarian Consultant, Eldersburg, MD, USA
C. V. Pollack, Jr. (ed.), Differential Diagnosis of Cardiopulmonary Disease,
https://doi.org/10.1007/978-3-319-63895-9_17
Jr. ()
269© Springer Nature Switzerland AG 2019
270
• There are primary chest masses and secondary masses. Secondary masses are
metastatic lesions that have primary tumors somewhere other than the chest.
• Primary tumors of the chest include:
• Breast cancer
• Lung cancer
• Esophageal cancer
• Primary cardiac tumors
• Primary tumors of the ribs and spine
• Soft tissue sarcomas
• Mesothelioma
• Multiple myeloma
• Lymphoid tumors
• Many different types of tumors can metastasize to the chest.
C. J. Rees et al.
Pathophysiology andEtiology
• Pathophysiology varies based on primary vs metastatic etiology, and invasive
vs more benign tissue types.
• There are behavioral (e.g., smoking) and genetic (e.g., BRAC1 gene) predispositions to chest tumors.
Presentation
Typical/“Classic”
• Tumors within the chest are often asymptomatic.
• They are most commonly found during diagnostic studies for other reasons.
• Symptoms, if present, are usually the result of direct compression from tumors
or direct inltration into surrounding structures. If the surrounding structures
inltrated are blood vessels, hemoptysis may result.
• Lymphoproliferative tumors often cause constitutional symptoms.
• Bronchogenic carcinoma may present as a postobstructive pneumonia.
• Breast or chest wall tumors may be palpable or painful, prompting
presentation.
Atypical
• Fulminant presentations with respiratory insufciency or massive hemoptysis
are unusual.
• Vague constitutional symptoms, such as nagging cough and weight loss, may
be presenting symptoms.
17 Chest Neoplasms
Primary Differential Considerations
Prompt consideration also should be given to the possible diagnosis of:
• Pneumonia and other infectious etiologies
• Thymus enlargement
• Pneumoconiosis
• Pulmonary nodule
History andPhysical Exam
Findings That Conrm Diagnosis
• The diagnosis is usually conrmed only through pathologic interpretation of
biopsy specimens.
Factors That Suggest Diagnosis
• These are often asymptomatic and found incidentally when performing diagnostic imaging studies for other reasons.
271
Factors That Exclude Diagnosis
• Advanced imaging studies (CT, MRI) can exclude masses of signicance.
Ancillary Studies
Laboratory
• Laboratory studies are sometimes helpful in evaluating chest masses. There
may be evidence of lymphoproliferative disorders on a complete blood count.
Multiple myeloma is often associated with anemia, renal insufciency, hypercalcemia, and an anion gap less than 5.
Imaging
• Most chest neoplasms are found incidentally during diagnostic imaging of the
chest for other reasons.