Special Operations Forces Medical Handbook

4-15

sputum for Gram stain and culture; Effusion uid for gram stain and WBC differential; CXR: effusion shadow
overlying lungs, and possible enlarged heart.

Assessment:
Differential Diagnosis
Transudative effusion - congestive heart failure, liver failure (any cause), nephrotic syndrome (any cause).
Exudative effusion - infection– bacterial (empyema), fungal, tuberculosis; cancer (lung or metastatic); collagen
vascular disease/rheumatoid arthritis, lupus; vascular – pulmonary embolus; unknown – granulomatous

Plan:

Treatment

1. Treat the primary disorder if possible.
   a. Give antibiotics for pneumonia (see Pneumonia Section).
   b. If a transudative effusion is suspected, give a trial of Lasix 20-60 mg po qd-bid


2. Perform thoracentesis (see following section) to improve breathing, if Lasix ineffective or in the face of
   unimproving pneumonia.
   a. Withdraw 30 cc of fluid for diagnostic laboratory evaluation or
   b. Draw off the effusion if fluid accumulation compromises respiratory status. Try not to remove more
   than 1000-1500 cc of fluid in the first 24 hours (can repeat procedures). Removing too much fluid can
   cause rapid fluid shifts in the lung tissue, which worsens hypoxemia (newly expanded lung is poorly
   perfused) and causes hypotension.
   c. A chest tube thoracostomy MUST be performed if the fluid is infected (see Procedures chapter).


3. Administer 30-40% oxygen since these patients are commonly hypoxic.

Patient Education
Activity: Bedrest with indwelling chest tube initially.
Diet: High protein diet unless liver failure is present, then diet must be modied to avoid hepatic encephalopa-
thy

Follow-up Actions
Return Evaluation: Refer patients that do not improve for specialty care and additional special studies.
Evacuation/Consultation Criteria: Evacuate unstable patients, or those who require on-going thoracente-
ses. Consult internist or pulmonologist.

Respiratory: Thoracentesis

COL Warren Whitlock, MC, USA

What: Thoracentesis the removal of pleural uid percutaneously by needle aspiration to determine the cause of
uid accumulation or to relieve the symptoms associated with the uid accumulation.

When: Perform a diagnostic thoracentesis when the presence of fluid in the pleural space is confirmed
by physical examination (and preferably by CXR), and the likelihood of bacterial infection in the fluid is high
(worsening condition despite broad spectrum antibiotics, lying with affected side down, progressive fever
and lethargy).
Risks: Thoracentesis is a relatively safe procedure; however, some relative contraindications include history
of coagulopathy (increase risk of bleeding), pleural effusion of insufcient volume (little uid layering on lateral
decubitus chest lm), and underlying severe respiratory disease. Complications of thoracentesis include
pneumothorax, bleeding, infection, puncture of abdominal organs, and pulmonary edema of the reinated lung.
The most common major complication is pneumothorax. Thoracentesis can cause a pneumothorax in two
ways: by introducing air through the back of the syringe or needle hub into the pleural space (it does not
progress to complete pneumothorax and does not require treatment), or by an accidental puncture of the lung.
If the patient is symptomatic, keep him under observation and follow the patient's progress with a serial CXR.