REFREC024
THORACIC SURGERY REFERRAL RECOMMENDATIONS
Diagnosis / Symptomatology
/Evaluation
/Management Options
/Referral Guidelines
This specialty may be subdivided under the following headings:· Congenital (Adult and Adolescent)
· Infectious
· Neoplastic
· Trauma
· Vascular / Standard examination, history and investigations are indicated below. However, most Thoracic Surgery diagnoses are evaluated via General and Respiratory Specialist Medical Services.
These referral recommendations should be cross-referred to Respiratory Medicine referral recommendations. / Specific treatments depend on specific problems identified as noted. However, in the context of Thoracic Surgery, management is essentially surgical. / These guidelines are provided (below) to give greater clarity in situations of the primary/secondary interface of care, as well as with other specialty services and the thoracic surgery service. Clear telephone/fax communication would enhance appropriate treatment.
Diagnosis / Symptomatology
/Evaluation
/Management Options
/Referral Guidelines
Congenital (Adult and Adolescent)
Pectus abnormalitiesLung Cysts / Standard history and examination:
KEY POINTS:
· Respiratory and cardiovascular symptoms.
· Shortness of breath.
Investigations:
· CXR AP + lateral./ CAT SCAN / Until growth has ceased surgery would not be advised unless the deformity is severe.
Large cysts (i.e.>5cm) and/or if complications develop (i.e. sepsis,bleed,rupture) require surgery / Refer to respiratory medicine – Category 3.
Diagnosis / Symptomatology
/Evaluation
/Management Options
/Referral Guidelines
InfectiousLung abscess / Standard history and examination.
KEY POINTS:
· Cough and excessive purulent sputum.
· Fever.
· Haemoptysis.
· May have no signs.
· History of inhalation of foreign body.
· Alcoholic.
· Altered mental state i.e alcohol abuse etc
Investigations:
· Sputum spec.
· FBC.
· CXR including lateral film. / Early surgical referral if :
Large>5cm/ increasing size
Haemoptysis
Rupture into pleural space (i.e. empyema)
Investigations;
Bronchoscopy mandatory to exclude
foreign body/tumour
Dental examination essential / Refer to Respiratory Medicine Service if patient is acutely ill – Category 1. Refer to Respiratory Medicine Service if there are abnormal CXR findings – Category 2.
Empyema and chest wall infection. / KEY POINTS:
· Pleuritic pain.
· Fever.
· Usually no sputum.
· Antecedent pneumonia. / Early surgical assessment critical
Bronchoscopy mandatory
Requires effective drainage, a well placed and maintained chest tube may avoid the need for thoracotomy
Inadequate drainage, loculations , trapped lung indicate need for surgery; thrombolytic via chest tube may be effective in specific cases. / Refer to Respiratory Medicine Service for confirmation of diagnosis and treatment as Category 1.
Chronic empyema should be referred as Category 2.
General Physician/Respiratory Physician will be involved in further imaging, aspiration and drainage. Thoracic Surgical referral is from Respiratory/General Physician.
Post surgical chest wall infections should be referred back to the original treating surgeon.
Referral to Respiratory Medicine for recurrent infection as Category 3.
Bronchiectasis / KEY POINTS:
· Chronic cough with purulent sputum.
· Haemoptysis.
· History of childhood whooping cough, measles, or other severe chest infection.
· Finger clubbing.
· Persistent crackles in chest. / · Stop smoking.
· Antibiotics.
· Flu inoculations.
· Physiotherapy including postural drainage. / Referral to Respiratory Medicine Service haemoptysis or acute exacerbation as Category 1.
Referral to Thoracic Surgery Service from Respiratory/General Medicine Service – Category 3.
TB / Referral for surgery from Respiratory/ General Physicians – Category 3.
Diagnosis / Symptomatology
/Evaluation
/Management Options
/Referral Guidelines
NeoplasticBenign/malignant
Pulmonary/pleural / Standard history and examination.
KEY POINTS:
· Asbestos exposure.
· Smoking history.
· Chronic obstructive airways disease.
· Asthma.
· Family history of disease.
May be symptomatic (cough, chest, infection, haemoptysis, hypertrophic pulmonary osteoarthropathy evidence of metastases, eg. cachexia, loss of weight, cerebral symptoms, bone pain) or asymptomatic (usually detected on CXR).
Investigations:
· CXR. / Note comments in general referral template / Refer to Respiratory Physician/General Physician for evaluation as Category 1.
Referral for Thoracic Surgery is from Respiratory Physicians.
(Note: Pulmonary secondary tumours should be evaluated for possible treatment.)
Mediastinal/chest wall masses / KEY POINTS:
· Respiratory stridor.
· SVC obstruction may be asymptomatic (detected on routine CXR).
· May have thyroid enlargement, myasthenia Gravis.
· Chest wall deformity.
· Mass on chest wall or pain.
· Asbestos exposure.
Investigations:
· CXR. / Key issues are:
Where is it? Need CT chest
What is it? Need fine needle biopsy
Posterior mediastinal masses require CT focus on possible vertebral canal involvement. / Refer to Respiratory Physician for evaluation with referral on to appropriate specialty as Category 1.
Oesophagus
(c.f. Gastroenterology and General Surgery referral recommendations.) / KEY POINTS:
· Dysphagia.
· Weight loss.
· Past history of reflux oesophagitis, hiatus hernia, smoking, achalasia.
Investigations:
· CXR.
· Routine FBE, LFT, UE.
· Consider Ba swallow if endoscopy referral difficult/delayed. / Refer to Gastroenterology or GS for evaluation and subsequent onward referral as necessary to Thoracic Surgery/GS – Category 1.
Diagnosis / Symptomatology
/Evaluation
/Management Options
/Referral Guidelines
TraumaThis covers:
· Ruptured diaphragm
· Chest wall injuries
· Fractured ribs
· Fractured sternum
· Pulmonary contusions
· Haemothorax
· Pneumothorax / KEY POINTS:
· Vital signs.
· Site of trauma.
· Physical examination.
· Investigations:
· CXR to exclude underlying pulmonary injury and collection. / For rural GP’s; ensure a chest tube is in the pleura and it will not be kinked during transfer.
Hence ; never clamp a chest tube and avoid dressings/pads covering the chest tube. A simple square dressing with a cut through the middle to allow the chest tube to exit is all that is required.
If possible maintain chest tube on 5kPa suction at all times. / Referral to Emergency Service for acute or severe injuries for initial resuscitation prior to onward referral to appropriate Surgical Service.
Minor or moderate trauma, eg simple haemopneumothorax could be managed by General Surgical Services, but severe chest trauma may require referral through to the Thoracic Surgery Service. Telephone communication to Thoracic Service is deemed necessary in these situations.
Foreign body.
(c.f. ENT/Paediatric Surgery referral recommendations.) / KEY POINTS:
· History.
· Respiratory symptoms, eg stridor, wheeze. / First aid. / Refer Respiratory Medicine/Surgeon for bronchoscopy as Category 1.
Diagnosis / Symptomatology
/Evaluation
/Management Options
/Referral Guidelines
VascularTraumatic
High speed deceleration injury
Aneurysms / KEY POINTS:
· Anatomical site of trauma.
· Widening of mediastinum on CXR.
· Usually blunt chest trauma.
· Inequality or absence of pulse (unilateral).
· Presence of haemothorax.
· Hypotension.
Refer to Vascular Surgery Protocol. / Resuscitate and evacuate according to the Severely Injured Protocol.
Spontaneous pneumothorax / Refer to Respiratory Medicine Protocol. / Refer to Respiratory Medicine. Surgical management (eg Pleurodesis) may be considered after recurrent pneumothoraces.
Last updated February 2006 Page 5 of 6