tension pneumothorax hypotension that worsens with inspiration

Diagnosis and management of traumatic and tension pneumothoraces require a high level of cooperation among interprofessional healthcare team members. Treatment options and long-term results. 9 (1):[QxMD MEDLINE Link]. Despite descriptions of Valsalva maneuvers and increased intrathoracic pressures as inciting factors, spontaneous pneumothorax usually develops at rest. [QxMD MEDLINE Link]. 2011 Oct. 18 (10):1022-6. J Trauma. The endotracheal tube is in a good position. 1987 Dec. 92 (6):1009-12. The breach acts as a one-way valve. [37][38], Ventilator-related tension pneumothorax has been found to have dire outcomes and result in death more frequently. J Thorac Cardiovasc Surg. Needle decompression is done at the second intercostal space in the midclavicular line above the rib with an angio-catheter. Anxiety, cough, and vague presenting symptoms (eg, general malaise, fatigue) are less commonly observed. Pulmonary collapse and consolidation; the role of collapse in the production of lung field shadows and the significance of segments in inflammatory lung disease. [Full Text]. Positive pressure ventilation should be avoided initially, as it will increase the tension pneumothorax's size. J Trauma. This condition usually occurs when intrathoracic pressures become elevated, such as with an exacerbation of asthma, coughing, vomiting, childbirth, seizures, and a Valsalva maneuver. Lee CC, Lee SH, Chang IJ, Lu TC, Yuan A, Chang TA, et al. Broaddus VC, Mason RJ, Ernst JD, et al, eds. Tension pneumothorax is a clinical diagnosis requiring emergent needle decompression, and therapy should never be delayed for x-ray confirmation. Respiratory findings may include the following: Cardiovascular findings may include the following: Signs of spontaneous and iatrogenic pneumothorax are similar and depend on the underlying lung disease and extent of the pneumothorax. Spontaneous pneumothorax. Small-bore catheter versus chest tube drainage for pneumothorax. [QxMD MEDLINE Link]. Explain the importance of improving care coordination among interprofessional team members to provide the best outcomes for patients with tension pneumothorax. 2006 May. 27 (3):470-6. 14G intravenous cannula) can be inserted, typically in the 2nd intercostal space in the midclavicular line, to gain valuable time, before a larger underwater drain can be inserted 1. 4 (4):235-8. The air is outside the lung but inside the thoracic cavity. POCUS has sensitivity and specificity ranging from 90-100% for detecting pneumothorax. J Ultrasound Med. 2006. If multiple rib fractures occur along the midlateral (red arrows) or anterior chest wall (blue arrows), a flail chest (dotted black lines) may result, which may result in pneumothorax. Greenberg's text-atlas of emergency medicine. Schramel FM, Postmus PE, Vanderschueren RG. Imaging Chest x-ray [6] [8] Indications: all patients suspected of having pneumothorax Soldati G, Iacconi P. The validity of the use of ultrasonography in the diagnosis of spontaneous and traumatic pneumothorax. 2005 Aug. 128 (2):720-8. Secondary pneumothoraces are often more likely to recur, with cystic fibrosis carrying the highest recurrence rates at 68-90%. On examination, breath sounds are absent on the affected hemothorax and the trachea deviates away from the. [QxMD MEDLINE Link]. 5 (2):183-6. By definition, spontaneous pneumothorax is not associated with trauma or stress. [QxMD MEDLINE Link]. Emerg Med J. This will cause the lung to collapse on the ipsilateral side. This places pressure on the lung and can lead to its collapse anda shift of the surrounding structures. Chest. British Thoracic Society guidelines on respiratory aspects of fitness for diving. [18][19], Traumatic pneumothorax occurs secondary to penetrating (e.g., gunshot wounds, stab wounds) or blunt chest trauma. Pathogenesis and treatment of primary spontaneous pneumothorax: an overview. Brian J Daley, MD, MBA, FACS, FCCP, CNSC Professor and Program Director, Department of Surgery, Chief, Division of Trauma and Critical Care, University of Tennessee Health Science Center College of Medicine Catheter aspiration for simple pneumothorax. [Guideline] MacDuff A, Arnold A, Harvey J, BTS Pleural Disease Guideline Group. In stable patients, local anesthesia or adequate analgesia/sedation should be administered. [33]. If you log out, you will be required to enter your username and password the next time you visit. Tension pneumothorax arises from many causes and rapidly progresses to respiratory insufficiency, cardiovascular collapse, and ultimately death if not recognized and treated. Tagami R, Moriya T, Kinoshita K, Tanjoh K. Bilateral tension pneumothorax related to acupuncture. Iatrogenic pneumothorax is a traumatic pneumothorax that results from injury to the pleura, with air introduced into the pleural cavity secondary to a diagnostic or therapeutic medical intervention. Cyanosis and jugular venous distension can also be present. Curr Opin Pulm Med. [QxMD MEDLINE Link]. Am Surg. These trauma patients may have multiple tissue contusions and laserations. This chest radiograph shows pneumomediastinum (radiolucency noted around the left heart border) in this patient who had a respiratory and circulatory arrest in the emergency department after experiencing multiple episodes of vomiting and a rigid abdomen. Moore FO, Goslar PW, Coimbra R, Velmahos G, Brown CV, Coopwood TB Jr, et al. Resuscitation. Hypoxia. It is usually managed in the emergency department or the intensive care unit. Clinical presentation. J Ultrasound Med. Widened b. Comparison of the efficacy of novel two covering methods for spontaneous pneumothorax: a multi-institutional study. Other tension pneumothorax Chest Discomfort Chest Tightness Cough Cyanosis (Bluish Tinge to Skin) In severe cases, the increased pressure can alsocompress the heart, the contralateral lung, and the vasculature leading to hemodynamic instability and cardiac arrest in some cases. This activity reviews the presentation of tension and traumatic pneumothoraces, outlines evaluation and management strategies, and highlights the importance of early intervention and the role of the interprofessional team in evaluating and improving care for patients with this condition. Nonsmoking, non-alpha 1-antitrypsin deficiency-induced emphysema in nonsmokers with healed spontaneous pneumothorax, identified by computed tomography of the lungs. Prevalence of tension pneumothorax in fatally wounded combat casualties. Knowledge of necessary emergency thoracic decompression procedures is essential for all healthcare professionals. [QxMD MEDLINE Link]. 2001 Feb. 119 (2):590-602. 5. The pain is sharp, worsens with inspiration or coughing, and . Shah K, Tran J, Schmidt L. Traumatic pneumothorax: updates in diagnosis and management in the emergency department. Until a bleb ruptures and causes pneumothorax, no clinical signs or symptoms are present in primary spontaneous pneumothorax (PSP). Ann Emerg Med. [QxMD MEDLINE Link]. Bense L, Eklund G, Wiman LG. Causes of tension pneumothorax Trauma to the chest, including a punctured lung, is the usual cause of a tension pneumothorax. Chest. 1993. 2012 Mar. 22 (1): 8-16. Ann Thorac Surg. [QxMD MEDLINE Link]. COPD can mimic the appearance of pneumothorax on thoracic ultrasound. Lateral radiograph depicting tension and traumatic pneumothorax. Hyper-expansion. Mary C Mancini, MD, PhD, MMM is a member of the following medical societies: American Association for Thoracic Surgery, American College of Surgeons, American Surgical Association, Phi Beta Kappa, Society of Thoracic SurgeonsDisclosure: Nothing to disclose. The timely and accurate evaluation leadsto early interventions decreasing mortality and morbidity. Chen KY, Jerng JS, Liao WY, Ding LW, Kuo LC, Wang JY, Yang PC. 2004 Feb. 36 (2):190. [QxMD MEDLINE Link]. [QxMD MEDLINE Link]. [QxMD MEDLINE Link]. Acad Emerg Med. Chemical pleurodesis options includetalc, minocycline, doxycycline, or tetracycline. However, tension pneumothorax is typically symptomatic, and its features are more impressive than spontaneous pneumothorax. a. Bedside sonography for detection of postprocedure pneumothorax. What Can We Do? 22 (2):101; author reply 101-2. Advertisement 1979 Dec. 120 (6):1379-82. 7. This can occur within minutes. [QxMD MEDLINE Link]. The incidence is 5to 7 per 10,000 hospital admissions. A tension pneumothorax will have the same features as a simple pneumothorax with a number of additional features, helpful in identifying tension. Tsotsolis N, Tsirgogianni K, Kioumis I, Pitsiou G, Baka S, Papaiwannou A, Karavergou A, Rapti A, Trakada G, Katsikogiannis N, Tsakiridis K, Karapantzos I, Karapantzou C, Barbetakis N, Zissimopoulos A, Kuhajda I, Andjelkovic D, Zarogoulidis K, Zarogoulidis P. Pneumothorax as a complication of central venous catheter insertion. Martin M, Satterly S, Inaba K, Blair K. Does needle thoracostomy provide adequate and effective decompression of tension pneumothorax? Leslie MD, Napier M, Glaser MG. Pneumothorax as a complication of tumour response to chemotherapy. 50 (6):754-8. Thoracoscopic pleurodesis for primary spontaneous pneumothorax with high recurrence risk: a prospective randomized trial. Radiograph depicting a right-sided iatrogenic pneumothorax after transbronchial biopsy. Rezende-Neto JB, Hoffmann J, Al Mahroos M, Tien H, Hsee LC, Spencer Netto F, et al. Contralateral recurrence of primary spontaneous pneumothorax. Concurrently, patients should be stabilized, anda complete assessment of the airway, breathing, and circulation should be performed. 2004 Jun. Can J Surg. Hypotension worsens with inspiration due to increased intrathoracic pressure. Obstructive shock is one of the four types of shock, caused by a physical obstruction in the flow of blood. Patients with trauma tend to have an associated pneumothorax or tension pneumothorax 20% of the time. Patients may demonstrate shallower breaths as they attempt to avoid deep breathing that triggers pain. Dulchavsky SA, Schwarz KL, Kirkpatrick AW, Billica RD, Williams DR, Diebel LN, et al. McPherson JJ, Feigin DS, Bellamy RF. J Emerg Med. Pneumothorax can result in tension physiology as well though the hemodynamic compromise from this, when a patient is on mechanical ventilation, is usually quicker than with hemothorax. Traumatic pneumothoraces occur secondary to penetrating or blunt trauma, or they are iatrogenic. Describe the appropriate evaluation of tension pneumothorax. 2000 Aug. 55 (8):666-71. Hernandez C, Shuler K, Hannan H, Sonyika C, Likourezos A, Marshall J. 124 (7):833-6. Huang TW, Lee SC, Cheng YL, Tzao C, Hsu HH, Chang H, et al. Insertion of chest tube. 12 (4):268-72. Tension Pneumothorax Tension pneumothorax is the progressive built-up of air within the pleural space. Symptoms may include diaphoresis, splinting chest wall to relieve pleuritic pain, and cyanosis (in the case of tension pneumothorax). [11] These numbers are lowerif procedures are done under ultrasound guidance. 280 (18):1563-4. Symptoms of iatrogenic pneumothorax are similar to those of a spontaneous pneumothorax and depend on the age of the patient, the presence of underlying lung disease, and the extent of the pneumothorax. 2004 Mar. Dalton AM, Hodgson RS, Crossley C. Bochdalek hernia masquerading as a tension pneumothorax. [QxMD MEDLINE Link]. However, the risk of lung re-expanding quickly increases the risk of pulmonary edema. Computed tomography scan demonstrating secondary spontaneous pneumothorax (SSP) from radiation/chemotherapy for lymphoma. [Full Text]. The incidence is about 1to 13% but can increase up to 30% in certain situations. Simple aspiration versus chest-tube insertion in the management of primary spontaneous pneumothorax: a systematic review. Am Rev Respir Dis. Life-Threatening Simultaneous Bilateral Spontaneous Tension Pneumothorax - A case report -. Rebecca Bascom, MD, MPH is a member of the following medical societies: American Thoracic SocietyDisclosure: Nothing to disclose. Gonfiotti A, Santini PF, Jaus M, Janni A, Lococo A, De Massimi AR, et al. Mil Med. Gupta D, Hansell A, Nichols T, Duong T, Ayres JG, Strachan D. Epidemiology of pneumothorax in England. Radiograph of an older man who was admitted to the intensive care unit (ICU) postoperatively. [QxMD MEDLINE Link]. Please Note: You can also scroll through stacks with your mouse wheel or the keyboard arrow keys. 2002 Mar. Radiograph of a patient with a complete right-sided pneumothorax due to a stab wound. [QxMD MEDLINE Link]. Tension pneumothorax is a potentially life-threatening condition that medical professionals must treat as a medical emergency. Contributed by Scott Dulebohn, MD, Tension pneumothorax. All the above causes can further cause tension pneumothorax as well as: Traumatic and tension pneumothoraces are more common than spontaneous pneumothoraces. [QxMD MEDLINE Link]. Chemical pleurodesis is an alternative if the patient cannot tolerate mechanical pleurodesis. Mutations of the Birt Hogg Dube gene in patients with multiple lung cysts and recurrent pneumothorax. Clinical signs of a tension pneumothorax in the ventilated patient are comparably rapid, with arterial and mixed venous peripheral capillary oxygen saturation immediately decreasing 5. (2004) ISBN:0781736552. The first rib is often fractured posteriorly (black arrows). During a pneumothorax, communication develops between the pleural space and the lung, resulting in air movement from the lung into the pleural space. Pneumothorax is a rare complication of thoracic central venous catheterization in community EDs. 2006 May. 2012 Oct. 30 (8):1407-13. Assessment of pneumothorax resolution is usually done with serial chest X-rays. Successful management of occult pneumothorax without tube thoracostomy despite positive pressure ventilation. 20. Shostak E, Brylka D, Krepp J, Pua B, Sanders A. 2008 Jan. 64 (1):111-4. The occult pneumothorax: what have we learned?. In these situations, care coordination is vital, and having different team members trained and ready to act promptly is life-saving. Am Surg. [QxMD MEDLINE Link]. Women aged 30-40 years who present with onset of symptoms within 48 hours of menstruation, right-sided pneumothorax, and recurrence raise suspicion for catamenial pneumothorax. 37 (4): 819. [QxMD MEDLINE Link]. (2018) Journal of Ultrasound in Medicine. A tension pneumothorax causes progressive difficulty with ventilation as the normal lung is compressed. Signs such as seatbelt sign or steering wheel deformity are indicators for high-energy blunt thoracic trauma. [13], Tension pneumothoraces can developin 1to 2% of cases initially presenting with idiopathic spontaneous pneumothoraces. Then, when the patient has improved, the lung has fully expanded, and no air leaks are visible, the chest tube is ready to be removed. (2005) ISBN:0781745861. These signs should be carefully observed by inspection. Vinson DR, Ballard DW, Hance LG, Stevenson MD, Clague VA, Rauchwerger AS, Reed ME, Mark DG., Kaiser Permanente CREST Network Investigators. Shabir Bhimji, MD, PhD Cardiothoracic and Vascular Surgeon, Saudi Arabia and Middle East Hospitals [QxMD MEDLINE Link]. Eur Respir J. [QxMD MEDLINE Link]. 23 Likewise, hypotension and a markedly widened pulse pressure should raise concerns for. This. Tension pneumothorax during general anaesthesia is a rare but possibly deleterious event, especially where predisposing factors are absent or unknown, making diagnosis even challenging. Eventually, impaired venous return results in cardiac arrest and . In: StatPearls [Internet]. Pneumothoraces are classified as simple (no shift of mediastinal structures), tension (shift in mediastinal structures present), or open (air passing through an open chest wound). 1998 Nov 11. Rim T, Bae JS, Yuk YS. J Trauma. Decreased movement of the affected hemithorax. Unlike the obvious patient presentations oftentimes used in medical training courses to describe a tension pneumothorax, actual case reports include descriptions of the diagnosis of the condition being missed or delayed because of subtle presentations that do not always present with the classically described clinical findings of this condition or the complexity of the patient with critical illness or injury. Due to the valve effect air will be stuck inside the pleural space without any means of escape. [QxMD MEDLINE Link]. Tension pneumothorax occurs when the air enters the pleural space but cannot fully exit, similar to a one-way valve mechanism through the disrupted pleura or tracheobronchial tree. Is Lung Damage More Extensive in Marijuana or Cigarette Smokers? 25 (5, Suppl 1):1-28. [QxMD MEDLINE Link]. Plewa MC, Ledrick D, Sferra JJ. Acute onset of shortness of breath; diaphoresis; abdominal discomfort and/or nausea; neurological symptoms such as syncope, pre-syncope or dizziness; and global weakness/acute fatigue should prompt. 2006 Sep. 28 (3):637-50. [Full Text]. 2004 Oct 30. As the pressure increases, it will cause the mediastinum to shift towards the contralateral side, contributing further to hypoxemia. Tachycardia is the most common finding, and tachypnea and hypoxia may be present. 2005 Dec. 44 (12):1538-41. Causes of traumatic pneumothorax include the following: Iatrogenic (induced by a medical procedure). 31 (2): 242-4. 2. ), which permits others to distribute the work, provided that the article is not altered or used commercially. 60 (3):573-8. [QxMD MEDLINE Link]. J Trauma. Henry M, Arnold T, Harvey J., Pleural Diseases Group, Standards of Care Committee, British Thoracic Society. Note that the hole on a chest tube is outside the pleural space. [12] Iatrogenic pneumothorax usually causes substantial morbidity but rarely death. Charles W. Lanks, Vanessa Correa. A pilot study to derive clinical variables for selective chest radiography in blunt trauma patients. A non-tension pneumothorax is properly called a simple pneumothorax. Prevalence of tension pneumothorax in fatally wounded combat casualties. Decreased or absent breath sounds on the affected side. It is a life-threatening occurrence requiring both rapid recognition and prompt treatment to avoid a cardiorespiratory arrest. These are all life-threatening. Michael G Benninghoff, DO, MS Attending Physician in Pulmonary and Critical Care Medicine, Christiana Medical Center Barton ED, Rhee P, Hutton KC, Rosen P. The pathophysiology of tension pneumothorax in ventilated swine. 1993. [QxMD MEDLINE Link]. 2003 Jul-Aug. 70 (4):431-8. Air is trapped in the pleural cavity under positive pressure. Rarely, it is a complication of traumatic pneumothorax, when a chest wound acts as a one-way valve that traps increasing volumes of air in the pleural space during inspiration. Clinical characteristics, hospital outcome and prognostic factors of patients with ventilator-related pneumothorax. [QxMD MEDLINE Link]. Presentation is variable and may initially have no symptoms. In cases of severe chest trauma, there is an associated pneumothorax 50% of the time. Ball CG, Kirkpatrick AW, Feliciano DV. Korom S, Canyurt H, Missbach A, Schneiter D, Kurrer MO, Haller U, et al. We describe a case of a healthy middle-aged woman, who was planned to receive general anaesthesia for total thyroidectomy. Clinical manifestations of tension pneumothorax: protocol for a systematic review and meta-analysis. A sudden attack of chest pain is often the first symptom. The development of tension pneumothorax in patients who are ventilated will generally be of faster onset with immediate, progressive arterial and mixed venous oxyhemoglobin saturation decline and immediate decline in cardiac output. 13 (3):209-10. Symptoms of spontaneous pneumothorax might appear when a person is at rest. 37 (3):180-2. Gupta D, Hansell A, Nichols T, Duong T, Ayres JG, Strachan D. Epidemiology of pneumothorax in England. Hypotension that worsens with inspiration Hypotension that worsens with inspiration is associated with tension pneumothorax due to compression of the heart and great vessels (obstructive shock). For a general discussion, refer to the pneumothoraxarticle. Some options are abrasive scratchpad, dry gauze, or stripping of parietal pleura. Acta Anaesthesiol Scand. [QxMD MEDLINE Link]. [Traumatic Intercostal Lung Hernia Repaired by Video-assisted Thoracoscopic Surgery;Report of a Case]. Chest. As a result, hypoxemia, acidosis, and decreased cardiac output can lead to cardiac arrest and, ultimately, death if the tension pneumothorax is not managed in a timely fashion. [39]In another study, patients with procedure-related tension pneumothorax had better outcomescompared to pneumothoraces occurring in the ITU due to barotrauma.[40]. Computed tomography scan demonstrating a bulla in an asymptomatic patient. [QxMD MEDLINE Link]. A needle thoracostomy (e.g. Vallee P, Sullivan M, Richardson H, Bivins B, Tomlanovich M. Sequential treatment of a simple pneumothorax. Civilian spontaneous pneumothorax. Erik D Barton, MD, MS Associate Director, Assistant Professor, Department of Surgery, Division of Emergency Medicine, University of Utah Health Sciences Center, Erik D Barton, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American College of Sports Medicine, American Medical Association, and Society for Academic Emergency Medicine, Marc D Basson, MD, PhD, MBA, FACS Professor, Chair, Department of Surgery, Assistant Dean for Faculty Development in Research, Michigan State University College of Human Medicine, Marc D Basson, MD, PhD, MBA, FACS is a member of the following medical societies: Alpha Omega Alpha, American College of Surgeons, American Gastroenterological Association, Phi Beta Kappa, and Sigma Xi, H Scott Bjerke, MD, FACS Clinical Associate Professor, Department of Surgery, University of Missouri-Kansas City School of Medicine; Medical Director of Trauma Services, Research Medical Center; Clinical Professor, Department of Surgery, Kansas City University of Medicine and Biosciences, H Scott Bjerke, MD, FACS is a member of the following medical societies: American Association for the History of Medicine, American Association for the Surgery of Trauma, American College of Surgeons, Association for Academic Surgery, Eastern Association for the Surgery of Trauma, Midwest Surgical Association, National Association of EMS Physicians, Pan-Pacific Surgical Association, Royal Society of Medicine, Southwestern Surgical Congress, andWilderness Medical Society, Paul Blackburn, DO, FACOEP, FACEP Attending Physician, Department of Emergency Medicine, Maricopa Medical Center, Paul Blackburn, DO, FACOEP, FACEP is a member of the following medical societies: American College of Emergency Physicians, American College of Osteopathic Emergency Physicians, American Medical Association, and Arizona Medical Association, Jeffrey Glenn Bowman, MD, MS Consulting Staff, Highfield MRI, Andrew K Chang, MD Associate Professor, Department of Emergency Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Andrew K Chang, MD is a member of the following medical societies: American Academy of Emergency Medicine, American Academy of Neurology, American College of Emergency Physicians, and Society for Academic Emergency Medicine, John Geibel, MD, DSc, MA Vice Chair and Professor, Department of Surgery, Section of Gastrointestinal Medicine, and Department of Cellular and Molecular Physiology, Yale University School of Medicine; Director, Surgical Research, Department of Surgery, Yale-New Haven Hospital, John Geibel, MD, DSc, MA is a member of the following medical societies: American Gastroenterological Association, American Physiological Society, American Society of Nephrology, Association for Academic Surgery, International Society of Nephrology, New York Academy of Sciences, and Society for Surgery of the Alimentary Tract, Disclosure: AMGEN Royalty Consulting; ARdelyx Ownership interest Board membership, Tunc Iyriboz, MD Chief, Division of Clinical Image Management, Assistant Professor, Department of Radiology, Hershey Medical Center, Pennsylvania State University, Tunc Iyriboz, MD is a member of the following medical societies: American College of Radiology, American Medical Association, and Radiological Society of North America, Seema Jain Pennsylvania State University College of Medicine, Rick Kulkarni, MD Attending Physician, Department of Emergency Medicine, Cambridge Health Alliance, Division of Emergency Medicine, Harvard Medical School, Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine, Eric L Legome, MD Chief, Department of Emergency Medicine, Kings County Hospital Center; Associate Professor, Department of Emergency Medicine, New York Medical College, Eric L Legome, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, Council of Emergency Medicine Residency Directors, and Society for Academic Emergency Medicine, Pinaki Mukherji, MD Assistant Professor, Attending Physician, Department of Emergency Medicine, Montefiore Medical Center, Pinaki Mukherji, MD is a member of the following medical societies: American College of Emergency Physicians, Robert E O'Connor, MD, MPH Professor and Chair, Department of Emergency Medicine, University of Virginia Health System, Robert E O'Connor, MD, MPH is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American College of Physician Executives, American Heart Association, American Medical Association, Medical Society of Delaware, National Association of EMS Physicians, Society for Academic Emergency Medicine, and Wilderness Medical Society, Benson B Roe, MD Emeritus Chief, Division of Cardiothoracic Surgery, Emeritus Professor, Department of Surgery, University of California at San Francisco Medical Center, Benson B Roe, MD is a member of the following medical societies: Alpha Omega Alpha, American Association for Thoracic Surgery, American College of Cardiology, American College of Surgeons, American Heart Association, American Medical Association, American Society for Artificial Internal Organs, American Surgical Association, California Medical Association, Society for Vascular Surgery, Society of Thoracic Surgeons, and Society of University Surgeons, Joseph A Salomone III, MD Associate Professor and Attending Staff, Truman Medical Centers, University of Missouri-Kansas City School of Medicine; EMS Medical Director, Kansas City, Missouri, Joseph A Salomone III, MD is a member of the following medical societies: American Academy of Emergency Medicine, National Association of EMS Physicians, and Society for Academic Emergency Medicine, Daniel S Schwartz, MD, FACS Assistant Clinical Professor of Cardiothoracic Surgery, Mount Sinai School of Medicine; Chief of Thoracic Surgery, Huntington Hospital, Daniel S Schwartz, MD, FACS is a member of the following medical societies: American College of Chest Physicians, American College of Surgeons, Society of Thoracic Surgeons, and Western Thoracic Surgical Association, Robert L Sheridan, MD Assistant Chief of Staff, Chief of Burn Surgery, Shriners Burns Hospital; Associate Professor of Surgery, Department of Surgery, Division of Trauma and Burns, Massachusetts General Hospital and Harvard Medical School, Robert L Sheridan, MD is a member of the following medical societies: American Academy of Pediatrics, American Association for the Surgery of Trauma, American Burn Association, and American College of Surgeons, Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference, Milos Tucakovic, MD Fellow, Department of Internal Medicine, Sections of Pulmonary Disease, Allergy and Critical Care Medicine, Milton S Hershey Medical Center, Pennsylvania State College of Medicine, Milos Tucakovic, MD is a member of the following medical societies: American College of Physicians and American Medical Association. [17]This is due to impaired cardiac fillingand reduced venous return.

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