Ultrasound for Critical Care Physicians: Characteristic Findings in A Complicated Effusion

Emilio Perez Power MD, Madhav Chopra MD, Sooraj Kumar MD, Tammy Ojo MD, and James Knepler MD

Division of Pulmonary, Allergy, Critical Care and Sleep

University of Arizona College of Medicine

Tucson, AZ USA

Case Presentation

A 60-year-old man with right sided invasive Stage IIB squamous lung carcinoma, presented with a one week history of progressively worsening shortness of breath, fever, and chills. On admission, the patient was hemodynamically stable on 5L nasal cannula with an oxygen saturation at 90%. Physical exam was significant for a cachectic male in moderate respiratory distress using accessory muscles but able to speak in full sentences. His pulmonary exam was significant for severely reduced breath sound on the right along with dullness to percussion. His initial laboratory finding showed a mildly elevated WBC count 15.3 K/mm3, which was neutrophil predominant and initial chest x-ray with complete opacification of the right hemithorax. An ultrasound of the right chest was performed (Figure 1).

Figure 1. Ultrasound of the right chest, mid axillary line, coronal view.

Based on the ultrasound image shown what is the likely cause of the patient’s opacified right hemithorax?

1. Consolidation
2. Exudative pleural effusion
3. Pneumothorax
4. Transudative pleural effusion

Cite as: Power EP, Chopra M, Kumar S, Ojo T, Knepler J. Ultrasound for critical care physicians: characteristic findings in a complicated effusion. Southwest J Pulm Crit Care. 2018;17(6):150-2. doi: https://doi.org/10.13175/swjpcc122-18 PDF

October 2018 Critical Care Case of the Month: A Pain in the Neck

Robert A. Raschke, MD

Critical Care Medicine

HonorHealth Scottsdale Osborn Medical Center

Scottsdale, AZ USA

History of Present Illness

A 54-year-old man was admitted after he had a decline in mental status. He complained of neck and back pain for one week prior to admission for which he took acetaminophen. He was seen in the emergency department two days prior to admission and diagnosed with “arthritis” and prescribed oxycodone/acetaminophen and cyclobenzaprine. On the day of admission be became unresponsive and was transported by ambulance to the emergency department where he was intubated for airway protection.

Past Medical History, Social History, Family History

• Alcoholism
• Hepatitis C
• Esophageal varices
• Family history is noncontributory

Physical Examination

• Vitals: T 102° F, BP 150/60 mm Hg, P 114 beats/min, 20 breaths/min
• Unresponsive
• Dupuytren’s contractures, spider angiomata
• 3/6 systolic murmur
• Deep tendon reflexes 3+  
• Bilateral Babinski’s sign (toes upgoing)

Which of the following are diagnostic considerations at this time? (Click on the correct answer to be directed to the second of six pages)

1. Bacterial endocarditis
2. Hypoglycemia
3. Liver failure
4. 1 and 3
5. All of the above

Cite as: Raschke RA. October 2018 critical care case of the month: a pain in the neck. Southwest J Pulm Crit Care. 2018;17(4):108-13. doi: https://doi.org/10.13175/swjpcc098-18 PDF

Ultrasound for Critical Care Physicians: Who Stole My Patient’s Trachea?

Monika Kakol MD, Connor Trymbulak MSc, and Rodrigo Vazquez Guillamet MD

Department of Internal Medicine Department

University of New Mexico School of Medicine

Albuquerque, NM USA

A 73-year-old man with a past medical history of asthma-chronic obstructive pulmonary disease overlap syndrome and coronary artery disease presented to the emergency department with acute on chronic respiratory failure. The patient failed to respond to initial bronchodilator treatment and non-invasive positive pressure ventilation. A decision was made to proceed with endotracheal intubation and mechanical ventilation. Upper airway ultrasonography was used to confirm positioning of the endotracheal tube and the following images were obtained:

Figure 1. Longitudinal view of the trachea.

Figure 2. Transverse view of the trachea at the level of the tracheal rings.

What does the ultrasound depict (see Figures 1 & 2)? (Click on the correct answer for an explanation)

1. Endotracheal intubation
2. Esophageal intubation
3. Calcified tracheal rings
4. Thyroid

Cite as: Kakol M, Trymbulak C, Guillamet RV. Ultrasound for critical care physicians: Who stole my patient’s trachea? Southwest J Pulm Crit Care. 2018;17(2):72-5. doi: https://doi.org/10.13175/swjpcc102-18 PDF

August 2018 Critical Care Case of the Month

Emma Simpson, MD

Banner University Medical Center Phoenix

Phoenix, AZ USA

History of Present Illness

A 19-year-old gravida 1, para 0 woman in her early second trimester presented to the Emergency Department with intractable vomiting, green sputum icteric sclerae, chest pain, palpitations and weakness for one week prior to presentation. She was visiting the US from an island in Micronesia. The patient has been experiencing feelings of general malaise since the beginning of her pregnancy: she experienced severe nausea and vomiting throughout her first trimester, and a 4.5 kg weight loss in the 2 months prior to presentation.

PMH, SH, FH

Before becoming pregnant, the patient was active and healthy. She does not smoke and her family history is unremarkable.

Physical Examination

Physical exam showed a thin, small young woman. Her physical examination showed a tachycardia of 114 and icteric sclera but was otherwise unremarkable.

Which of the following should be done? (Click on the correct answer to proceed to the second of six pages)

1. Admit to the hospital with measurement of electrolytes, transaminases and bilirubin
2. Discharge to home with a prescription for pyridoxine/doxylamine
3. Ultrasound
4. 1 and 3
5. All of the above

Cite as: Simpson E. August 2018 critical care case of the month. Southwest J Pulm Crit Care. 2018;17(2):53-8. doi: https://doi.org/10.13175/swjpcc092-18 PDF 

Ultrasound for Critical Care Physicians: Caught in the Act

Uzoamaka Ogbonnah MD¹

Isaac Tawil MD²

Trenton C. Wray MD²

Michel Boivin MD¹

¹Department of Internal Medicine

²Department of Emergency Medicine

University of New Mexico School of Medicine

Albuquerque, NM USA

A 16-year-old man was brought to the Emergency Department via ambulance after a fall from significant height. On arrival to the trauma bay, the patient was found to be comatose and hypotensive with a blood pressure of 72/41 mm/Hg. He was immediately intubated, started on norepinephrine drip with intermittent dosing of phenylephrine, and transfused with 3 units of packed red blood cells. He was subsequently found to have extensive fractures involving the skull and vertebrae at cervical and thoracic levels, multi-compartmental intracranial hemorrhages and dissection of the right cervical internal carotid and vertebral arteries. He was transferred to the intensive care unit for further management of hypoxic respiratory failure, neurogenic shock and severe traumatic brain injury. Following admission, the patient continued to deteriorate and was ultimately declared brain dead 3 days later. The patient’s family opted to make him an organ donor

On ICU day 4, one day after declaration of brain death, while awaiting organ procurement, the patient suddenly developed sudden onset of hypoxemia and hypotension while being ventilated. The patient had a previous trans-esophageal echo (TEE) the day prior (Video 1). A repeat bedside TEE was performed revealing the following image (Video 2).

Video 1. Mid-esophageal four chamber view of the right and left ventricle PRIOR to onset of hypoxemia.

Video 2. Mid-esophageal four chamber view of the right and left ventricle AFTER deterioration.

What is the cause of the patient’s sudden respiratory deterioration? (Click on the correct answer to be directed to an explanation)

1. Atrial Myxoma
2. Fat emboli syndrome
3. Thrombus in-transit and pulmonary emboli
4. Tricuspid valve endocarditis

Cite as: Ogbonnah U, Tawil I, Wray TC, Boivin M. Ultrasound for critical care physicians: Caught in the act. Southwest J Pulm Crit Care. 2018;17(1):36-8. doi: https://doi.org/10.13175/swjpcc091-18 PDF