Ultrasound for Critical Care Physicians: Two’s a Crowd

A 43 year old previously healthy woman was transferred to our hospital with refractory hypoxemia secondary to acute respiratory distress syndrome (ARDS) due to H1N1 influenza. She had presented to the outside hospital one week prior with cough and fevers. Chest radiography and computerized tomography of the chest revealed bilateral airspace opacities due to dependent consolidation and bilateral ground glass opacities. A transthoracic echocardiogram at the time of the patient’s admission was reported as not revealing any significant abnormalities.

At the outside hospital she was placed on mechanical ventilation with low tidal volume, high Positive end-expiratory pressure (20 cm H20), and a Fraction of inspired Oxygen (FiO2) of 1.0. Paralysis was later employed without significant improvement.

Upon arrival to our hospital, patient was severely hypoxemic with partial pressure of oxygen / FiO2  (P/F) ratio of 43. She was paralyzed with cis-atracurium and placed on airway pressure release ventilation (APRV) with the following settings (pressure high 28 cm H2O, pressure low 0 cm H2O, time high 5.5 sec, time low 0.5 sec). The patient remained severely hypoxemic with on oxygen saturation in the high 70 percent range.

A bedside echocardiogram was performed (Figures 1 and 2).

Figure 1. Subcostal long axis echocardiogram.

Figure 2. Subcostal short axis echocardiogram

What abnormality is demonstrated by the short and long axis subcostal views? (Click on the correct answer for an explanation)

1. Acute cor pulmonale likely due to ARDS
2. Acute myocardial infarction
3. Low left-sided ejection fraction
4. Pericardial tamponade

Cite as: Abukhalaf J, Boivin M. Ultrasound for critical care physicians: two's a crowd. Southwest J Pulm Crit Care. 2016 Mar;12(3):104-7. doi: http://dx.doi.org/10.13175/swjpcc028-16 PDF

March 2016 Critical Care Case of the Month

Theo Loftsgard APRN, ACNP

Joel Hammill APRN, CNP

Mayo Clinic Minnesota

Rochester, MN USA

Critical Care Case of the Month CME Information

Members of the Arizona, New Mexico, Colorado and California Thoracic Societies and the Mayo Clinic are able to receive 0.25 AMA PRA Category 1 Credits™ for each case they complete. Completion of an evaluation form is required to receive credit and a link is provided on the last panel of the activity. 

0.25 AMA PRA Category 1 Credit(s)™

Estimated time to complete this activity: 0.25 hours

Lead Author(s): Theo Loftsgard APRN, ACNP.  All Faculty, CME Planning Committee Members, and the CME Office Reviewers have disclosed that they do not have any relevant financial relationships with commercial interests that would constitute a conflict of interest concerning this CME activity.

Learning Objectives:
As a result of this activity I will be better able to:

1. Correctly interpret and identify clinical practices supported by the highest quality available evidence.
2. Will be better able to establsh the optimal evaluation leading to a correct diagnosis for patients with pulmonary, critical care and sleep disorders.
3. Will improve the translation of the most current clinical information into the delivery of high quality care for patients.
4. Will integrate new treatment options in discussing available treatment alternatives for patients with pulmonary, critical care and sleep related disorders.

Learning Format: Case-based, interactive online course, including mandatory assessment questions (number of questions varies by case). Please also read the Technical Requirements.

CME Sponsor: University of Arizona College of Medicine

Current Approval Period: January 1, 2015-December 31, 2016

Financial Support Received: None

History of Present Illness

A 58-year-old man was admitted to the ICU in stable condition after an aortic valve replacement with a mechanical valve.

Past Medical History

He had with past medical history significant for endocarditis, severe aortic regurgitation related to aortic valve perforation, mild to moderate mitral valve regurgitation, atrial fibrillation, depression, hypertension, hyperlipidemia, obesity, and previous cervical spine surgery. As part of his preop workup, he had a cardiac catheterization performed which showed no significant coronary artery disease. Pulmonary function tests showed an FEV1 of 55% predicted and a FEV1/FVC ratio of 65% consistent with moderate obstruction.

Medications

Amiodarone 400 mg bid, digoxin 250 mcg, furosemide 20 mg IV bid, metoprolol 12.5 mg bid. Heparin nomogram since arrival in the ICU.

Physical Examination

He was extubated shortly after arrival in the ICU. Vitals signs were stable. His weight had increased 3 Kg compared to admission. He was awake and alert. Cardiac rhythm was irregular. Lungs had decreased breath sounds. Abdomen was unremarkable.

Laboratory

His admission laboratory is unremarkable and include a creatinine of 1.0 mg/dL, blood urea nitrogen (BUN) of 18 mg/dL, white blood count (WBC) of 7.3 X 10⁹ cells/L, and electrolytes with normal limits.

Radiography

His portable chest x-ray is shown in Figure 1.

Figure 1. Portable chest x-ray taken on admission to the ICU. 

What should be done next? (Click on the correct answer to proceed to the second of five panels)

1. Bedside echocardiogram
2. Diuresis with a furosemide drip because of his weight gain and cardiomegaly
3. Observation
4. 1 and 3
5. All of the above

Cite as: Loftsgard T, Hammill J. March 2016 critical care case of the month. Southwest J Pulm Crit Care. 2016;12(3):81-8. doi: http://dx.doi.org/10.13175/swjpcc018-16 PDF

February 2016 Critical Care Case of the Month

Thomas M. Stewart, MD

Bhargavi Gali, MD 

Department of Anesthesiology

Mayo Clinic Minnesota

Rochester, MN USA

Case Presentation

A 32 year-old, previously healthy, female hospital visitor had been participating in a family care conference regarding her critically ill grandmother admitted to the cardiac intensive care unit. During the care conference, she felt unwell and had some mild chest discomfort; she collapsed and cardiopulmonary resuscitation (CPR) was initiated (1). Upon arrival of the code team, she was attached to the monitor and mask ventilation was initiated. Her initial rhythm is shown in Figure 1.

Figure 1. Initial rhythm strip.

In addition to DC cardioversion which of the following should be administered immediately? (Click on the correct answer to proceed to the second of four panels)

1. Lidocaine
2. Magnesium sulfate
3. Procainamide
4. 1 and 3
5. All of the above

Cite as: Stewart TM, Gali B. February 2016 critical care case of the month. Southwest J Pulm Crit Care. 2016;12(2):41-5. doi: http://dx.doi.org/10.13175/swjpcc011-16 PDF 

Ultrasound for Critical Care Physicians: Hungry Heart

A 31-year-old incarcerated man with a past medical history of intravenous drug use and hepatitis C, presented with a one week history of dry, non-productive cough, orthopnea and exertional dyspnea. He denied current intravenous drug use, and endorsed that the last time he used was before he was incarcerated over 3 years ago, his last tattoo was in prison, 6 months prior. He was found to have an oxygen saturation of 77% on room air, fever of 40º C, heart rate of 114 bpm, and blood pressure of 80/50 mmHg. The patient had a leukocytosis of 14 x10⁹/L, and a chest x-ray demonstrating patchy airspace disease. Blood cultures were sent and he was treated with antibiotics and vasopressors for septic shock. The patient was intubated for acute hypoxemic respiratory failure secondary to multifocal pneumonia. A bedside transthoracic echocardiogram was performed. 

Figure 1. Apical four chamber view echocardiogram with color Doppler over the mitral valve.

Figure 2. Right Ventricular (RV) inflow view echocardiogram from same patient

What is the likely diagnosis supported by the echocardiogram? (Click on the correct answer for an explanation)

1. Massive pulmonary embolism
2. Mitral valve endocarditis
3. Pericardial tamponade
4. Tricuspid valve endocarditis

Cite as: Villalobos N, Stoltze K, Azeem M. Ultrasound for critical care physicians: hungry heart. Southwest J Pulm Crit Care. 2016;12(1):24-7. doi: http://dx.doi.org/10.13175/swjpcc007-16 PDF

January 2016 Critical Care Case of the Month

Sandra L. Till, DO

Banner University Medical Center Phoenix

Phoenix, AZ USA  

History of Present Illness

The patient is an 18-year-old woman who was driving to high school on a frontage road when she fell asleep at the wheel and her car rolled over. She was wearing her seatbelt but there was no airbag deployment. She did not lose consciousness and she was responsive and answering questions at the scene. She self-extricated from the vehicle. She had left arm pain with a boney deformity and she walked to the ambulance that transferred her to the hospital emergency department (ED).

Upon arrival in the ED she appeared pale and had difficulty breathing. In addition to her arm pain with an obvious left humeral fracture she also complained of upper abdominal and anterior chest pain. O2 saturation was initially 90% but declined to 70%.

Which of the following should be ordered immediately? (Click on the correct answer to proceed to the second of six panels)

1. Begin intravenous lines with large bore needles
2. X-ray of humerus
3. Hemoglobin and hematocrit
4. 1 and 3
5. All of the above

Cite as: Till SL. January 2016 critical care case of the month. Southwest J Pulm Crit Care. 2016;12:6-12. doi: http://dx.doi.org/10.13175/swjpcc151-15 PDF