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 

Ultrasound for Critical Care Physicians: The Pleura and the Answers that Lie Within

Heidi L. Erickson MD 

Division of Pulmonary, Critical Care and Occupational Medicine

University of Iowa Hospitals and Clinics

Iowa City, IA

A 67-year-old woman with a 40-pack-year smoking history was admitted to the intensive care unit with acute respiratory failure secondary to adult respiratory distress syndrome (ARDS) in the setting of pneumococcal bacteremia. On admission, she required endotracheal intubation and vasopressor support.  She was ventilated using a low tidal volume strategy and was relatively easy to oxygenate with a PEEP of 5 and 40% FiO2. After 48 hours of clinical improvement, the patient developed sudden onset tachypnea and increased peak and plateau airway pressures. A bedside ultrasound was subsequently performed (Figures 1 and 2).

Figure 1. Two- dimensional ultrasound image of the right lung with associated M-mode image.

Figure 2. Two- dimensional ultrasound image of the left lung with associated M-mode image.

What is the cause of this patient’s acute respiratory decompensation and increased airway pressures? (Click on the correct answer for an explanation)

1. Pericardial effusion
2. Pneumothorax
3. Pulmonary edema
4. Pulmonary embolism

Cite as: Erickson HL. Ultrasound for critical care physicians: the pleura and the answers that lie within. Southwest J Pulm Crit Care. 2015;11(6):260-3. doi: http://dx.doi.org/10.13175/swjpcc149-15 PDF

December 2015 Critical Care Case of the Month

Samir Sultan, DO 

Banner University Medical Center Phoenix

Phoenix, AZ 

History of Present Illness

The patient is a 32-year-old woman who presented with flank pain for 3 days to an outside hospital. She was diagnosed with pyelonephritis and begun on ceftriaxone. She was discharged against medical advice on cephalexin.

She returned to the same hospital 3 days later by ambulance with labored breathing and weakness and was emergently intubated. She was transferred for ventilator management and respiratory failure.

Past Medical History

She has a long history of poorly controlled diabetes mellitus.

Physical Examination

She is orally intubated and sedated.

Vitals: Temperature - 100.9º F, Blood Pressure - 117/75 mm Hg, Heart Rate - 148 beats per minute,  Respiratory Rate - 31 breaths/min, SpO2 - 88 % on assist control of 30, tidal volume of 350 mL, PEEP 15, and an FiO2 100%.

There is scatted rhonchi and rales but the remainder of the physical examination is unremarkable.

Radiography

Her admission portable chest X-ray is shown in Figure 1.

Figure 1. Admission portable AP of the chest.

Which of the following should be ordered as part of her initial work-up? (Click on the correct answer to proceed to the second of five panels).

1. Administer broad spectrum antibiotics
2. Blood and urine cultures
3. Rapid influenza test
4. 1 and 3
5. All of the above

Cite as: Sultan S. December critical care case of the month. Southwest J Pulm Crit Care. 2015;11(6):246-51. doi: http://dx.doi.org/10.13175/swjpcc147-15 PDF

Ultrasound for Critical Care Physicians: 50 Ways to Line Your Liver

Seth Skiles ACNP

Theresa Heynekamp MD MPH

Division of Pulmonary, Critical care and Sleep Medicine,

University of New Mexico School of Medicine

Albuquerque, NM USA

A 54-year-old man with a past medical history significant for traumatic brain injury and aspiration pneumonia presented with hypoxic respiratory failure secondary to foreign body aspiration.

On presentation, the patient was found to be hypoxic and tachypneic, requiring endotracheal intubation and mechanical ventilation. Bronchoscopy was performed with removal of extensive food particles throughout both lungs. The patient subsequently developed sepsis secondary to aspiration pneumonia.  He became hypotensive, requiring central venous catheter placement for vasopressor therapy. A right subclavian central line was attempted under ultrasound guidance. A beside ultrasound was subsequently performed (Video 1).

Video 1. Sagittal view of the liver and heart at the level of the mid-abdomen and slightly right of mid-line.

What does the video obtained of a longitudinal view of the IVC at the level of the liver demonstrate? (Click on the correct answer for a discussion)

1. Endocarditis
2. Guidewire in the hepatic vein
3. Hemopericardium
4. Pneumothorax

Cite as: Skiles S, Heynekamp T. Ultrasound for critical care physicians: 50 ways to line your liver. Southwest J Pulm Crit Care. 2015;11(5):235-7. doi: http://dx.doi.org/10.13175/swjpcc144-15 PDF

November 2015 Critical Care Case of the Month

Samir Sultan, DO

Banner University Medical Center Phoenix

Phoenix, AZ

 History of Present Illness

A 39-year-old Caucasian woman was admitted to the ICU with worsening dyspnea and increasing oxygen requirements. Her lips turned blue with minimal activity. She was admitted to another hospital 5 months earlier with pneumonia. At discharge she was placed on oxygen. At follow-up with her pulmonologist, she was diagnosed with sleep apnea.

Past Medical History, Family History, Social History

• She has a history of an optic glioma at age 7 with resection followed by radiation therapy and development of panhypopituitarism.
• Liver cirrhosis diagnosed in 2014 with presentation of hematemesis.
• Type 2 diabetes mellitus
• Denies tobacco, ethanol, or illicit drug use.
• There is a family history of diabetes and liver cirrhosis

Physical Examination

• Vital signs:110 / 86, HR 97, RR 16, 88% on 6 liter O2
• General: obese female (BMI 35) in no apparent distress
• Chest: Clear to auscultation bilaterally
• Cardiovascular: regular rate without murmur or rub
• The remainder of the physical exam is normal  

Radiography

      A chest x-ray was interpreted as normal.

Laboratory

• CBC: hemoglobin 13.8 gm/dL, WBC 7 X 103 cells/microliter with a normal differential
• Basic metabolic panel: Na⁺ 132 mEq/L, K⁺ 4 mEq/L, Cl^- 100 mEq/L, HCO3^- 22 mEq/L, glucose 150 mg/dL.
• Arterial blood gases (ABGs): PaO₂ 35 mm Hg, PaCO₂ 37 mm Hg, pH 7.43

Which of the following is/are not possible cause(s) of hypoxemia in this patient? (Click on the correct answer to proceed to the second of six panels)

1. Decreased diffusion (alveolar capillary block)
2. Ventilation-perfusion mismatch
3. Hypoventilation
4. 1 and 3
5. All of the above

Cite as: Sultan S. November 2015 critical care case of the month. Southwest J Pulm Crit Care. 2015;11(5):209-15. doi: http://dx.doi.org/10.13175/swjpcc137-15 PDF