1 CHEST TRAUMA

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3 Trachea Lungs Bronchi Mediastinum

4 BOUNDARIES Of The ChestSuperiorly => clavicles Inferiorly => diaphragm Laterally => rib cage

5 Anteriorly => sternum Posteriorly => vertebral bodies & ribs

6 Any organ in chest potentially susceptibleStructures Injured Any organ in chest potentially susceptible especially to penetrating trauma

7 Contents Of Thoracic CavityChest wall and ribs. Lungs and pleura. Great and thoracic vessels. Heart and mediastinal structures. Diaphragm

8 Esophagus Thoracic duct Tracheobronchial system

9 Other Organs At Risk Thoraco-abdominal injuryany wound below nipples in front and inferior scapula angles dorsally may result in intra abdominal injury.

10 Peritoneal viscera OTHER ORGANS AT RISK Liver Spleen StomachColon & small intest. Biliary system Retro-peritoneum kidneys

11 Resulting Injuries Rib fractures Sternal fracturesSubcutaneous emphysema Open or Closed Pneumothorax - unilateral / bilateral Hemothorax Hemopneumothorax Pneumo-mediastinum Pulmonary contusion Myocardial contusion Diaphragmatic rupture

12 Chest injuries may result from:Vehicle accidents. Falls. Gunshot wounds. Crush injuries. Stab wounds.

13 Second leading cause of trauma deaths after head injury.Accounts for 25% of all trauma deaths. 2/3 of deaths occur after reaching hospital. -Vital Structures Serious pathological consequnces: hypoxia, hypovolaemia, myocardial failure. Abdominal injuries are common with chest trauma.

14 Mechanism of Injury Blunt injuries Either:direct blow (e.g. rib fracture) compression injury Rib fracture is the most common sign of blunt thoracic trauma Fracture of scapula, sternum, or first rib suggests massive force of injury. Mostly managed non-operatively.

16 Penetrating injuries E.g. Gunshot or stab wounds etc.Primarily it might affect peripheral lung Haemothorax. Pneumothorax. Cardiac, great vessel or oesophageal injury.

17 Mechanism of Injury PENETRATING Low energy Medium energy High energy

18 Penetrating (Low energy)Impalements Knife wounds => disrupts only structures penetrated

19 Penetrating (Medium energy)Bullet wounds from most handguns

20 Penetrating (High energy)From military weapons+ Shotguns (low velocity) Transfers kinetic energy to tissues => cavitation => high velocity. Amount of tissue damage proportional to amount of energy exchanged between the penetrating object and the body part.

22 Pathophysiology Quite serious

23 1. HYPOXIA / HYPOVENTILATIONPrimary acute killer of trauma patients inadequate delivery of O2 to tissues.

24 Signs of HYPOXIA Increased RR Change in breathing pattern (shallow) Anxious behavior Poor air movement Dilated pupils Cyanosis – (late sign)

25 Inadequate intravascular volume => BLOOD LOSS2. Hypovolemia Inadequate intravascular volume => BLOOD LOSS

26 3. Ventilation / Perfusion MismatchContusion Hematoma Alveolar collapse

27 4. CHANGES IN INTRATHORACIC PRESSURE RELATIONSHIPS- Tension pneumothorax - Open pneumothorax

28 Hypoperfusion of tissues (shock)5. METABOLIC ACIDOSIS Hypoperfusion of tissues (shock)

30 Massive hemothorax Open pneumothorax Cardiac tamponade Flail chest2. PRIMARY SURVEY Tension pneumothorax Massive hemothorax Open pneumothorax Cardiac tamponade Flail chest => Aim to identify & treat immediately life threatening conditions

31 Assess the casualty Identify signs and symptoms Airway BreathingCirculation

32 Signs Indicative Of Seriouse Chest InjuryShock Cyanosis Hemoptysis Chest wall contusion Flail chest Open wounds Distended neck veins Tracheal deviation Subcutaneous emphysema

33 Assess Vital Signs Pulse Blood pressure Respiratory rate

34 Assess the Skin Pallor-pale Cyanosis Open wound Ecchymosis-bruising

35 Assess the Neck Position of trachea Subcutaneous emphysema Jugular venous distention Penetrating wounds

36 Assess the Chest Contusions Tenderness AsymmetryOpen wounds or impaled objects Crepitation Paradoxical movement

37 Lung sounds Absent or decreased Unilateral Bilateral Bowel sounds in chest

38 Percussion Hyperresonance Hyporesonance (hemothorax)(pneumothorax-tension pneumothorax) Hyporesonance (hemothorax)

39 Compare both sides of the chest at the same time when assessing for asymmetry.

41 Heart sounds Muffled (cardiac tamponade) Distant

42 CXR Invistigaions => basis for initiating other investigations=> UPRIGHT if possible

43 FAST Focused Abdominal Sonography for Trauma (FAST)- All hemodynamically unstable blunt trauma pts

44 Cat Scan Becoming a primary diagnostic tool

45 3.Detailed Secondary SurveyMay show: Simple pneumothorax Hemothorax Pulmonary contusion Myocardial contusion Blunt aortic injury Rib fractures Diaphragmatic rupture

46 Usually operative Most life threatening injuries txd by4. Definitive care Most life threatening injuries txd by - Airway control - Chest tube Usually operative

48 Rib Fracture

49 Rib Fracture Most common chest injury Especially common in elderlyFractures of the Scapula or the first or second rib requires a significant force This should alert you to the possibility of major thoracic vascular injury 20-30% of patients with fractures of the 1st or 2nd ribs die of associated injuries, 5% die of a ruptured aorta

50 Ribs form rings Consider possibility of break in two places.Fractures of 8th to 12th ribs can damage underlying abdominal solid organs: Liver Spleen Kidneys

51 Localized pain, tendernessSigns and Symptoms Localized pain, tenderness Increases when patient: Coughs Moves Breathes deeply Chest wall instability Deformity, discoloration - Crepitus Associated pneumo or hemothorax

52 Management Simple Rib Fracture Pain Management (PCA) Monitor for pneumothorax or hemothorax Encourage deep breathing, Patients will fail to breath deeply and cough, resulting in poor clearance of secretions ( Pulmonary toilet) . Monitor elderly and COPD patients carefully

53 Flail Chest

54 Flail chest

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56 Usually secondary to blunt trauma. More common in older patients.Usually 2 fractures per rib in at least 2 ribs or more or separation of sternum from ribs. Produces free-floating chest wall segment (Segment of chest wall that does not have continuity with rest of thoracic cage). Segment does not contribute to lung expansion. Disrupts normal pulmonary mechanics. Accompanied by pulmonary contusion in 50% of patients with flail chest. Usually secondary to blunt trauma. More common in older patients.

57 Flail segment moves with Paradoxical motionSigns and Symptoms Flail segment moves with Paradoxical motion May NOT be present initially due to intercostal muscle spasms Be suspicious in any patient with chest wall: Tenderness Crepitus

58 Force also causes pulmonary contusionObserve for hemo or pneumothorax Pain from injury causes increased hypoxia

59 Consequences Pain, leading to decreased ventilation Increased work of breathing Contusion of lung

60 Treatment Establish airway Administer oxygen or Assist ventilationAnalgesia for pain (IV Morphine) Initiate IV - may need to limit fluids Monitor heart for myocardial trauma Stabilize chest wall ,manual pressure to stabilize flail segment, then apply bulky dressing

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62 Operative fixation not usually required (historical)

63 Lung Injuries Pneumothorax Hemothorax

64 Pneumothorax It is accumulation of air within space between visceral and parietal pleura. Partial or complete lung collapse occurs. Severity of symptoms depends on size of pneumothorax, speed of lung collapse.

65 Pneumothorax (closed)

66 Pneumothorax

67 May be caused by blunt trauma or may be spontaneousOver pressurization ( eg. blast, diving) May occur spontaneously following: Exertion Coughing Air Travel

68 Signs and symptoms Pleuritic chest pain, Pain on inhalation Dyspnea Decreased or absent breath sounds Hypertympany to percussion

69 Management Administer oxyge Chest tube

70 Open Pneumothorax Open sucking chest woundallows free passage of air into and out pleural cavity => effective ventilation impaired => hypoxia

72 Open Pneumothorax

73 Management Cover site with sterile occlusive dressing taped on three sides. High flow O2. Chest tube.

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75 Tension Pneumothorax One-way valve forms in lung or chest wall, created from either penetrating or blunt trauma . Air enters thoracic space but cannot escape, pressure builds and further collapses the lung and forces mediastinum and heart away from effected lung. May also compromise good lung.

76 Tension Pneumothorax Air pushes over heart and collapses lungAir outside lung from wound Heart compressed not able to pump well

77 Collapses ipsilateral lung

78 Displaces mediastinum to opposite side

79 Compresses opposite lung

80 Decreases venous return

81 Tension Pneumothorax Signs & Symptoms sever dyspnea ( air hunger)chest pain tachycardia tracheal deviation absent breath sounds hyper-resonant percussion JVP Restlessness, anxiety, agitation Cyanosis Subcutaneous emphysema

82 Surgical emergency Rx: emergency decompression before CXREither large bore cannula in 2nd ICS, MCL or insert chest tube

83 Immediate decompression Confirmation Auscultaton & Percussion Pleural Decompression 2nd intercostal space in mid-clavicular line TOP OF RIB Consider multiple decompression sites if patient remains symptomatic Large over the needle catheter: 14ga Administer oxygen chest tube as definitive tx

84 Hemothorax Blood in pleura spacecommon result of major chest wall trauma Present in 70 to 80% of penetrating & major non-penetrating chest trauma

85 Shock precedes ventilatory failureSigns and Symptoms Decreased breath sounds Dullness to percussion Dyspnea Ventilatory failure Shock precedes ventilatory failure

86 Signs and Symptoms Rapid, weak pulse Cool, clammy skin Restlessness, anxiety Thirst Chills Hypotension Collapsed neck veins

87 Management Assist breathing with high concentration O2 Decompression by Chest tube (most need just that). Bleeding may stop when lung re-expands

88 Massive Hemothorax Loss of 1500 cc blood or 200 cc per hour from the chest tube Pleural cavity hold 3 liters blood 200cc in chest cavity seen on CXR 90% from internal mammary or intercostals 10% from pulmonary vessels

89 Signs and symptoms Hypotension from blood loss or compression of great vessels Dullness to percussion Decreased breath sounds Anxiety or confusion secondary to hypovolemia or hypoxia

90 Managemen oxygen Initiate IV to carefully replace fluids Chest tube Thoracotomy

91 Pulmonary Contusion Common injury produced by blunt trauma, which may be potentially lethal Most common chest injury in children Bruising of lung can produce marked hypoxemia Usually develops over 24 hours Can occur with or without laceration of parenchyma

92 - Significant inflammatory reaction to blood components in the lungResults from: Leakage of blood and fluid into interstitial spaces of lung - Significant inflammatory reaction to blood components in the lung

93 Loss of normal lung structure & function leads toPathophysiology Loss of normal lung structure & function leads to - poor gas exchange - increased pulmonary vascular resistance - decreased lung compliance

94 Complications Atelectasis Pneumonia ARDS Respiratory failure

95 Diagnosis Parenchymal infiltrate seen in CXR adjacent to injured chest wall

96 Diagnosis No real clinical findings especially initially dyspneachest wall contusions / abrasions

97 Treatment MOSTLY supportive - usually resolve in 5-8 days.- O2 + observation in milder cases. - Pain control to allow: - adequate ventilation and better management of secretions. - Fluid restriction. - Intubation + mechanical ventilation if respiratory distress present.

98 Indications for intubationRespiratory distress Co-morbidities esp. lung disease Other injuries – intra-abdominal

99 Tension pneumothorax Massive hemothorax Cardiac tamponade2. PRIMARY SURVEY Flail chest Open pneumothorax Tension pneumothorax Massive hemothorax Cardiac tamponade => Aim to identify & treat immediately life threatening conditions

100 Myocardial Contusion Potentially lethal lesion resulting from blunt chest injury. Usually associated with fractures of the sternum. Any severe anterior chest injury.

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102 Difficult To Dx => HIGH LEVEL OF SUSPICION Sign & Symptoms:-chest pain, dysrhythmias, cardiogenic shock. May mimic a myocardial infarction. ALL pts with pattern of injury must have an ECG

103 Diagnosis Ectopy ST elevation Tachycardia Enzymes may be normal

104 Management Administer oxygen Analgesi. ECG monitoring,pulse oximetry (if availabl). Monitor in ICU & treat dysrhythmias Serial enzymes

105 Cardiac Tamponade

106 Cardiac tamponade

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108 Usually secondary to penetrating traumaBlood rapidly collects between heart and pericardium, this pressure compresses the ventricles and prevents the ventricles from filling, which decreases cardiac output. Small amounts of fluids <100ml can cause this

109 Signs and Symptoms Shock JVP Dyspnea Beck’s triad = minority of pts - Distended neck veins - Muffled heart sounds - Hypotension

110 Management administer oxygenInitiate IV - a bolus of electrolyte solution ( ml) may increase filling of the heart and increase cardiac output Rapidly fatal and not easily treated in field Initiate cardiac monitoring

111 Treatment Volume resuscitation. Pericardiocentesis. Surgery:- Pericardial window - Sternotomy - Thoracotomy

112 Diaphragmatic (Rupture) TearsTraumatic herniation of abdominal contents into the chest

115 Frequent injury in thoracoabdominal trauma Can result from a severe blow to abdomen 15% stab wounds 46% GSW 15% greater than 2cm long

116 Signs and symptoms No distinctive signs / symptoms seen High index of suspicion needed especially with mechanism of injury. May be no immediate herniation of abdominal contents. Abdomen can appear scaphoid dyspnea with diminished breath sounds cyanosis shoulder pain bowel sounds in lower chest

117 Up to 13% acute injuries missed initiallyTreatment Up to 13% acute injuries missed initially 85% presenting in 3 years as - obstruction or with - decreased cardio / pulmonary reserve Goal of treatment: - Maintain adequate oxygenation => intubate - NG decompression of stomach

119 Esophageal Injuries Diagnosis Treatment Most due to penetrating trauma- Difficult - If delayed => rapid sepsis & high mortality - Requires aggressive investigation - Radiography - Endoscopy - Thoracoscopy Treatment - Thoracotomy, etc.

120 Thoracic Duct InjuriesAccompany thoracic vessel injuries Noted much later i.e. not in acute phase Huge morbidity due to severe nutritional depletion Mn => initially aggressive and nonoperative = hyperalimentation => TPN and if not sealed in 5-7 days surgical intervention

121 Traumatic Aortic RuptureViewed from behind

122 Most common cause of deaths in high speed MVA and falls from heights, 90% die immediatelyDiagnosis is difficult in the field High index of suspicion in above types of accidents

123 Often rapidly fatal Only 10% survive to hospital Only 20% survive > 1 hour 90% who reach hospital will die EARLY DX and aggressive tx best chance

124 Mediastinum > 8cm wide Blurring of aortic knobDiagnosis Mediastinum > 8cm wide Blurring of aortic knob

125 Operative repair Treatment

126 Tracheobronchial Tree InjuryResults from blunt or penetrating trauma Penetrating injuries frequently have associated major vascular injuries Presenting signs include: Dyspnea Hemoptysis Subcutaneous emphysema of chest, neck, or face Associated pneumothorax or hemothorax

127 Management Administer oxygen Observe for pneumothorax/hemothorax

128 Traumatic Asphyxia Signs and symptoms12/16/2017 Traumatic Asphyxia Severe compression injury to the chest Compression of heart and mediastinum Signs and symptoms Cyanosis and swelling of the head and neck Lips and tongue may be swollen Conjunctival hemorrhage may be evident Body below the injury remains pink

129 12/16/2017

130 Impalement Injuries Management Caused by penetrating object (s)DO NOT remove object Management Ensure airway and oxygen Stabilize object Initiate large bore IV and treat for shock

132 Needle Chest DecompressionIndications Tension Pneumothorax with any two: Respiratory Distress & Cyanosis Decreasing Level of Consciousness Loss of Radial Pulse (hypovolemia) Required Materials 12 to 14 gauge I.V. needle w/catheter 5 cm long Betadine or Alcohol Prep Pads Surgical Gloves (2 pair) Tape

133 Identify the following anatomical landmarks on the side of the tension pneumothoraxMid-clavicular line Second intercostal space - superior edge of the 3rd rib

134 Needle Chest Decompression

135 Steps for performing the procedurePosition of Casualty: this procedure is not dependant on any single position that the casualty may be in or able to be moved to. Casualty may be lying flat, sitting etc.

136 Site preparation: accomplished using either alcohol and or betadine prep pads to disinfect the skinUsing your index finger trace the mid- clavicular line, then identify the second intercostal space (between the second and third ribs) on the side of the tension pneumothorax

137 Steps for performing the procedur;Insert the needle perpendicular to the chest wall, directly over the top of the third rib until a palpable pop is felt followed immediately by a hissing of air escaping from the chest cavity A rush of air confirms the diagnosis and rapidly improves the patient's condition

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139 Complications Laceration of the intercostal vessels or nerve may cause hemorrhage or nerve damage Creation of a pneumothorax may occur if not already present Infection is a possibility

140 Chest tube insertion Most common interventionRelatively simple procedure Definitively manage > 85% of chest trauma : penetrating or blunt Has significant complication rate (2-19%). May be minor but May require operative intervention and Can result in death

141 Chest tube Drain contents of pleural spaceair blood chyle gastric contents Prevent development of pleural collection i.e. after thoracotomy Prevent tension pneumothorax in ventilated pt with rib fractures

142 Chest tube insertion Indications:-Relative indications Rib fractures and positive pressure ventilation. Profound hypoxia/hypotension with penetrating chest injury. Absolute indications Pneumothorax. Hemothorax.

143 Placement may be Diagnostic or TherapeuticBright red blood suggest arterial injury = possible thoracotomy Intestinal contents esophageal, stomach, diaphragm intestinal injury Large air leak - bronchial disruption Technique = important to avoid complications

145 Chest tube insertion AnalgesiaPainful especially in muscular pts Morpine IV or Ketamine 20mg in adult 10-20 ml local analgesia along line of incision perpendicularly thru all layers of chest wall to rib below space up into pleural cavity after aspirating air

146 Chest tube insertion ProcedurePrep and drape Incise along upper border of the rib below the intercostal space to be used Track is to be directed over top of lower rib so as to avoid intercostal vessels lying below each rib should be big enough to fit finger Use curved clamp to develop tract by blunt dissection only – use to spread the muscle fibers, develop tract with fingers On reaching rib, clamp angled upward just above the rib and dissection continued till pleural space entered

147 Chest tube insertion ProcedureFinger inserted into pleural space and area palpated 32-36 F tube attached to clamp and inserted along track into the pleural cavity

148 Chest tube insertion ProcedureConnect tube to underwater seal and suture in place Examine chest to check effect CXR to check placement and position

149 POSITION - Dependent on direction of tractPenetrating Posteriorly & basally directed drain Last hole should be INSIDE the CHEST CAVITY If too far in could cause severe intractable pain when up against mediastinum Blunt chest trauma pts lying flat place drain anteriorly prevents blockage of tube and development of tension pneumothorax

150 Chest tube insertion Underwater SealAllows air to ESCAPE but NOT RE-ENTER chest cavity Negative pressure dependent upon level of water Pleurovac must always be below level of patient Persistent bubbling = air leak from lung

151 Chest tube insertion Underwater SealMay be connected to suction (water level 20cm H2O) Aid lung re-expansion especially if there is an air leak CHEST TUBES SHOULD NEVER BE CLAMPED = TENSION PNEUMOTHORAX

152 Chest Tube Removal How? Occlude hole while pulling tube.Remove at end of expiration or at peak of inspiration. Avoids air being drawn into cavity. Remove rapidly and close wound quickly. When? When no air leak No more fluid draining

153 Chest tube insertion Complications“there is no organ in the thoracic or abdominal cavity that has not been pierced by a chest drain” mainly historical since drains used to be inserted with - a steel trocar - excessive force

154 Chest tube insertion Acute complicationsHemothorax – usually laceration of intercostals vessel, may require thoracotomy Lung laceration especially when adhesions present Diaphragm / abdominal cavity penetration - placed too low Stomach colon injury - diaphragmatic hernia not recognized Tube placed subcutaneously – not in pleural cavity Tube placed too far = pain Tube falls out = not secured properly

155 Chest tube insertion Late complicationsblocked tube = clot, lung retained hemothorax empyema pneumothorax after removal = poor technique

156 Chest trauma summary Common SeriousPrimary goal is to provide oxygen to vital organs Remember Airway Breathing Circulation Be alert to change in clinical condition Managed MOST of the time with a CHEST TUBE

157 END CHEST TRAUMA

158 Pulmonary Hydatid Cysts

160 Echinococcosis or hydatid disease is caused by larvae of the tapeworm Echinococcus.Four species are recognised in humans and the vast majority of infestations are caused by E. granulosus. Humans are exposed less frequently to E. multilocularis, which causes alveolar echinococcosis. E. vogeli and E. oligarthrus are rare species and cause polycystic echinococcosis.

161 The E. granulosus requires two hosts to complete its life cycle.Dogs are the definitive host and a variety of species (sheep, cattle, horses, pigs, camels and humans) are the intermediate host. Humans are accidental hosts and are usually infected by handling an infected dog. and do not play a role in the biological cycle. The liver and lungs are the most frequently involved organs. Pulmonary disease appears to be more common in younger individuals.

162 Epidemiology Public health problems are encountered in endemic areas, such as South America, the Middle East, Africa, Russia, China, Australia and New Zealand.

163 Parasite Biology The fully developed cysts are composed of three layers. The outer layer, or pericyst, is composed of inflamed fibrous tissue derived from the host. The exocyst is an acellular laminated membrane. The innermost layer, or endocyst, is the germinative layer of the parasite and gives rise to brood capsules (secondary cysts), which bud internally. An intact cyst, if large, may be filled with litres of fluid. The fluid, which is antigenic and may contain debris, contains hooklets and scolices and is referred to as hydatid sand. It has characteristic radiographic and sonographic features . Daughter cysts may develop directly from the endocyst, resulting in multicystic structure.

164 Organ involvement Following ingestion of EOrgan involvement Following ingestion of E. granulosus eggs, the cyst can be found in virtually any organ (primary echinococcosis). Secondary echinococcosis results from the spread of the hydatid cyst from the primary sites. Patients with cystic echinococcus, 85–90% show single organ involvement and 70% harbour a solitary cyst. The liver is the most common site of cyst formation, followed by the lung in 10–30% of cases and other sites (usually the spleen, kidney).

165 Pathogenesis: ingestion of the parasite eggs ,contain embryos (oncospheres) which penetrate the intestinal mucosa and enter the blood and lymphatic system, movement to visceral organs

166 Clinical features The initial infection is asymptomatic and remain for many years. Seen at any age and sex, more common 20–40 yrs. Most cysts are discovered incidentally on chest radiographs. Unruptured cyst results in cough, haemoptysis or chest pain . Small cysts remain asymptomatic indefinitely, but enlarge cyst to 20 cm in diameter cause symptoms by compressing adjacent structures.

167 The cyst may rupture spontaneously or as a result of trauma or secondary infection.Rupture may be associated with the sudden onset of cough and fever. If the contents of the cyst are expelled into the airway, expectoration of a clear salty tasting fluid containing fragments of hydatid membrane and scolices may occur. Symptoms result from the release of cyst antigenic material and immunological reactions that develop , Fever and acute hypersensitivity reactions ranging from urticaria and wheezing to life-threatening anaphylaxis may be the principal manifestations.

168 Diagnostic work-up: Plain chest radiograph ( CXR)Typical chest radiographic appearances pulmonary hydatid disease are one or more homogeneous round or oval masses with smooth borders surrounded by normal lung tissue . If the ruptured cyst When it has completely collapsed, the endocyst floats freely in the cyst fluid (water-lily sign). Computerised tomography (CT). (MRI). Ultrasound: screening abdominal cysts, follow-up after treatment

169 CXR

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173 CT SCAN

174 CT SCAN

175 MRI

176 Laboratory eosinophilia : less than 15% of cases exhibit.Serology: An enzyme-linked immunosorbent assay or indirect haemagglutination test. Histopathological examination: visualisation of cyst wall with scolices or remnants( hooklets) using Ziehl-Neelsen stain.

177 Management Surgical treatment.For patients who are able to undergo surgery, it is considered the treatment of choice since the parasite can be completely removed and the patient cured, cure rate: 90%. Pre-surgery: medical treatment with albendazole: recommended, at dose of mg/kg per day in two gifts. (at least four days before surgery and to continue for at least one to three months). The surgical options for lung cysts include lobectomy, wedge resection, pericystectomy.

178 Scolicidal agents such as hypertonic saline, cetrimide, povidone-iodine, formalin, ethanol or hydrogen peroxide may be used, it must remain in contact with the cyst for o15 min. Most surgeons use 1% formaldehyde or hypertonic saline solution for deactivation of cysts and protection of the operative field.

179 Medical treatment. Therapy is usually indicated for 3–6 months.Albendazole , Mebendazole, Praziquantel. Albendazole is preferred because it has better bioavailability. Albendazole is given at a dosage of 10– 15 mg\ kg body weight\ day in two divided doses and the usual dose is 800 mg daily. Drugs only: patients with inoperable disease, multiple cysts (2 or more organs), after incomplete surgery or relapse, for prevention of secondary spread following rupture and where surgery facilities are not available.

180 Prevention Avoiding close contact with dogs.Careful washing of fresh produce can also reduce infection. Vaccination is also a prospect for prevention of echinococcosis, since protective immunity develops in intermediate hosts