Ultrasound for Critical Care Physicians: Ghost in the Machine

Ross Davidson, DO

Michel Boivin, MD 

Division of Pulmonary, Critical Care and Sleep Medicine

University of New Mexico School of Medicine

Albuquerque, NM USA

A 53-year-old woman presented to the emergency department after a sudden cardiac arrest at home. The patient had a history of asthma and tracheal stenosis and had progressive shortness of breath over the previous days. The patient’s family noticed a “thump” sound from the patient’s room, and found her apneic. They called 911 and began cardiopulmonary resuscitation. Paramedics arrived on the scene, found an initial rhythm of pulseless electrical activity. The patient eventually achieved return of spontaneous circulation and was transported to the hospital. On arrival the patient was in normal sinus rhythm, with a heart rate of 110 beats per minute. Blood pressure was 80/45 mmHg, on an epinephrine infusion. The patient was afebrile, endotracheally intubated, unresponsive and ventilated at 30 breaths per minute. An initial chest radiograph was compatible with aspiration pneumonitis and a small pneumothorax. Initial electrocardiogram on arrival had 1mm ST-segment depressions in leads V4 to V6. Transthoracic echocardiography was unsuccessful due to patient’s habitus and mechanical ventilation. Because of the patient’s hemodynamic instability and unknown cause of cardiac arrest, an urgent trans-esophageal echocardiogram (TEE) was performed (Videos 1-3).

Video 1. Mid-esophageal 4-chamber view of the heart.

Video 2. Upper esophageal long-axis view of the pulmonary artery and short axis view of the ascending aorta.

Video 3. Upper esophageal short axis view of the pulmonary artery with the ascending aorta in long axis. 

Based on the images presented what do you suspect is the etiology of the patient’s cardiac arrest? (Click on the correct answer for an explanation-no penalty for guessing, you can go back and try again)

1. Massive Pulmonary Embolism
2. Myocardial infarction
3. Pericardial Tamponade
4. Unable to determine

Cite as: Davidson R, Boivin M. Ultrasound for critical care physicians: ghost in the machine. Southwest J Pulm Crit Care. 2018;16(2):76-80. doi: https://doi.org/10.13175/swjpcc027-18 PDF 

February 2018 Critical Care Case of the Month

Robert A. Raschke, MD

University of Arizona College of Medicine-Phoenix

Phoenix, AZ

History of Present Illness

A 25-year-old was admitted to an outside hospital with an acute episode of nausea and vomiting and chronic progressive weakness.  He smoked 2 cigarettes per day and drank a 12-pack of beer per month.  He had a history of undefined chronic liver disease.

Physician Examination

Physical examination was reported as showing a chronically ill appearing man who was “weak” using crutches to ambulate.

The patient was made NPO and was rehydrated with intravenous normal saline.

Which of the following are indicated at this time? (Click on the correct answer to proceed to the second of four pages)

1. Creatinine phosphokinase (CPK)
2. Serum potassium
3. Thyroid studies
4. 1 and 3
5. All of the above

Cite as: Raschke RA. February 2018 critical care case of the month. Southwest J Pulm Crit Care. 2018;16(2):62-6. doi: https://doi.org/10.13175/swjpcc009-18 PDF

January 2018 Critical Care Case of the Month

Theodore Loftsgard, APRN, ACNP 

Department of Anesthesiology and Critical Care

Mayo Clinic Minnesota

Rochester, MN USA

History of Present Illness

The patient is a 51-year-old woman admitted with a long history of progressive shortness of breath.  She has a long history of “heart problems”. She uses supplemental oxygen at 1 LPM by nasal cannula.

Past Medical History, Social History and Family History

She also has several comorbidities including renal failure with two renal transplants and a history of relatively recent RSV and CMV pneumonia. She is a life-long nonsmoker. Her family history is noncontributory.

Physical Examination

• Vital signs: Blood pressure 145/80 mm Hg, heart rate 59 beats/min, respiratory rate 18, T 37.0º C, SpO2 91% of 1 LPM.
• Lungs: Clear.
• Heart: Regular rhythm with G 3/6 systolic ejection murmur at the base.
• Abdomen: unremarkable.
• Extremities: no edema

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

1. Brain naturetic peptide (BNP)
2. Chest x-ray
3. Echocardiogram
4. Electrocardiogram
5. All of the above

Cite as: Loftsgard T. January 2018 critical care case of the month. Southwest J Pulm Crit Care. 2018;16(1):1-7. doi: https://doi.org/10.13175/swjpcc155-17 PDF

December 2017 Critical Care Case of the Month

Michael B. Gotway, MD

Department of Radiology

Mayo Clinic Arizona

Scottsdale AZ USA

Clinical History: A 57-year-old man with no known previous medical history was brought to the emergency room via ambulance and admitted to the intensive care unit with a compliant of severe chest pain in the substernal region and epigastrium. The patient was awake and alert and did not complain of shortness of breath.

Physical examination was largely unremarkable and the patient’s oxygen saturation was 98% on room air. The patient’s vital signs revealed tachycardia (105 bpm) and his blood pressure was 108 mmHg / 60 mmHg.

Laboratory evaluation showed a slightly elevated white blood cell count (13 x 10⁹ cells/L), but his hemoglobin and hematocrit values were with within normal limits, as was his platelet count. 

Which of the following diagnoses are appropriate considerations for this patient’s condition? (Click on the correct answer to proceed to the second of nine pages)

1. Acute pericarditis
2. Aortic dissection
3. Community-acquired pneumonia
4. Myocardial infarction
5. All of the above

Cite as: Gotway MB. December 2017 critical care case of the month. Southwest J Pulm Crit Care. 2017;15(6):241-52. doi: https://doi.org/10.13175/swjpcc145-17 PDF 

November 2017 Critical Care Case of the Month

Stephanie Fountain, MD

Pulmonary and Critical Care Medicine

Banner University Medical Center Phoenix

Phoenix, AZ USA

History of Present Illness

A 56-year-old man presented with “food stuck in throat” since eating steak 18 hours prior to presentation. He is unable to eat or drink and has a sore throat. He is able to speak but has a “hoarse voice.” He denied drooling.

Past Medical History, Family History, and Social History

• He described himself as “healthy” and had not sought medical care in years.
• Former smoker but quit 2 years ago.
• He uses alcohol daily.
• He denied illicit drug use.

Physical Exam

• Afebrile, blood pressure 137/74 mm HG, heart rate 74 beats/min, SpO2 98% on room air.
• Physical exam was normal

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

1. Esophagogastroduodenoscopy (EGD)
2. Papain (Adolph’s Meat Tenderizer®) administration
3. Tracheostomy
4. 1 and 3
5. All of the above

Cite as: Fountain S. November 2017 critical care case of the month. Southwest J Pulm Crit Care. 2017;15(5):191-8. doi: https://doi.org/10.13175/swjpcc130-17 PDF