Ultrasound for Critical Care Physicians: Tiny Bubbles

Kashif Aslam, MD

Michel Boivin, MD

Division of Pulmonary, Critical care and Sleep Medicine

University of New Mexico School of Medicine

Albuquerque, NM

A 59 year old woman with a past medical history significant for stage IV MALT lymphoma (after chemotherapy and in remission) presented from a long term care facility for respiratory distress and altered mental status. The patient was in hypercarbic respiratory failure with a severe lactic acidosis. Her blood pressure deteriorated, she was begun on vasopressors and intubated.  Pertinent labs demonstrated a white blood cell count of 0.9 X10⁶ /ml, a hemoglobin of 7.1 g/dl, and a platelet count 66 X10⁶  /ml. The patient was started on Cefepime and Linezolid presumptively for septic shock. Ultrasounds of her thorax were performed (Videos 1 & 2).

Video 1.  Ultrasound of the right thorax in the mid-axillary line. 

 

Video 2.  Ultrasound of the right thorax in the mid-axillary line (slightly more caudad).

What is the best explanation for the ultrasound findings shown above? (Click on the correct answer for an explanation)

1. Large pleural effusion
2. Pneumothorax
3. Consolidation due to pneumonia
4. Ruptured diaphragm
5. Lung abscess

Reference as: Aslam K, Boivin M. Ultrasound for critical care physicians: tiny bubbles. Southwest J Pulm Crit Care. 2015;10(5):216-9. doi: http://dx.doi.org/10.13175/swjpcc067-15 PDF

May 2015 Critical Care Case of the Month: An Infected Leg

Sandra L. Till DO and Robert A. Raschke MD

Banner University Good Samaritan Medical Center

Phoenix, AZ

History of Present Illness

A 46-year-old transferred due to concern for necrotizing fasciitis. One the day prior to transfer purple discoloration was not noted in the lower portion of the left leg. On the day of transfer the leg became more purple, painful, and swollen. She presented to a pain clinic that advised her to go to an emergency room. The emergency room performed arterial Doppler ultrasound, which was normal and transferred her due to concern of necrotizing fasciitis.

Past Medical History, Social History and Family History

She has a past medical history of fibromyalgia. She had an extensive surgical history including an appendectomy, bladder implant, cholecystectomy, dilatation and curettage, esophageal repair, left femoral artery repair due to a motor vehicle accident, partial hysterectomy, left knee surgery, and several left leg operations with grafting. Family history was non-contributory. The patient was single with two children, and smoked 1-2 packs of cigarettes per day for 30 years. She denied any illicit drugs or alcohol abuse.

Medications

• Zolpidem
• Warfarin
• Furosemide
• Potassium Chloride
• Morphine sulfate
• Gabapentin
• Oxycodone
• Alprazolam
• Ondansetron
• Amitriptyline

Physical Examination

Vitals signs: Blood pressure 128/85 mm Hg, pulse 86 beat/min, respiratory rate 12, temperature 36.7º C, SPO2 96% on 2L/min of oxygen.

General: Non-toxic, alert and oriented x3, tearful due to pain.

The remainder of the physical examination was unremarkable except for the left lower extremity (Figure 1).

Figure 1. Photograph of the patient's left leg.

Which of the following are appropriate at this time? (Click on the correct answer to proceed to the second of five panels)

1. Blood cultures
2. Complete blood count, c-reactive protein, sodium, creatinine and glucose
3. Surgery consult
4. Wound culture
5. All of the above

Reference as: Till SL, Raschke RA. May 2015 critical care case of the month: an infected leg. Southwest J Pulm Crit Care. 2015;10(5):208-15. doi: http://dx.doi.org/10.13175/swjpcc045-15 PDF

April 2015 Critical Care Case of the Month: Half-Sided Light House

Theodore Loftsgard APRN, ACNP, CCRN

Adam Frost RRT, CRT

Dacia Evans RN

Karen Kolbet PharmD, RPh

Division of Critical Care

Mayo Clinic

Rochester, Minnesota

History of Present Illness

A 55 year old woman was transferred to the ICU from the general medicine ward for tachycardia and acute hypoxic respiratory distress. She has multiple myeloma and had received cycle one of bortezomib, dexamethasone, thalidomide, cisplatin, doxorubicin, cyclophosphamide and etoposide (VDT-PACE) and radiotherapy to T7 for a pathologic compression. She was admitted for pain control from mucositis.

Past Medical History

In addition to the multiple myeloma she has a past medical history of asthma, ovarian cysts, diverticulitis, eczema, pneumonia, laparoscopic cholecystectomy, total abdominal hysterectomy with bilateral salpingo-oophorectomy, appendectomy, ectopic pregnancy in the past, and left Bell's palsy.

Current Medications

• Acyclovir 400 mg BID
• Albuterol 90 HFA prn
• Allopurinol 300 mg daily
• Fluconazole 200 mg BID
• Gabapentin 300 mg BID,
• Hydromorphone
• Levofloxacin 500 daily
• Morphine
• Omeprazole
• Bactrim 400-80 mg daily for PCP prophylaxis
• Thalomid 200 mg capsule daily
• Ativan 0.5 mg just prior to transfer

Physical Examination

• Vital Signs: temperature 36.4 °C, respiratory rate 24 breaths/minute, blood pressure 148/77 mm Hg, pulse 133/minute, SpO2 98% on oxygen at 4 L/min.
• General: Alert and follows commands. Slightly somnolent. In respiratory acute distress.
• Skin: Pink, warm and dry without acute rashes or lesions.
• Eyes: EOMs intact. Conjunctivae pink. Sclerae anicteric
• ENT: Neck supple. Trachea midline.
• Cardiac: S1, S2 irregular rate and rhythm without extra sounds, murmurs, rubs or gallops. Capillary refill 2 seconds.
• Lungs: Respirations with accessory muscle use, shallow. scattered crackles and equal to auscultation. Diminished bilateral bases.
• Abdomen: Soft. No abdominal tenderness. Non-distended. Bowel sounds present.
• Extremities: Peripheral pulses +2/4 throughout. 1+ peripheral edema.
• Neuro: GCS = 13, residual bell's palsy.

Pertinent Labs

• Sodium: 144 mmol/L
• Potassium: 4.2 mmol/L
• Chloride: 113 mmol/L *
• Bicarbonate,: 23 mmol/L
• Creatinine: 0.6 mg/dL
• Hematocrit: 20.5 %
• Leukocytes: 0.5 x10(9)/L
• Hemoglobin: 6.2 g/dL
• Platelet Count: 39 x10(9)/L
• Calcium, Ionized(S): 4.81 mg/dL
• pH (FOR CALCIUM, IONIZED [S]): 7.47
• INR: 1.5
• APTT(P): 29 sec

Her ECG (Figure 1) showed a tachycardia with a maximum heart rate was in the 170's.

Figure 1. Admission ECG to the ICU.

Her admission chest x-ray is shown in Figure 2.

Figure 2. Portable chest x-ray taken just after admission to the ICU.

Which of the following are true? (Click on the correct answer to proceed to the second of four panels)

1. The EKG shows atrial fibrillation with a rapid ventricular response
2. She should be immediately intubated for airway protection
3. The chest x-ray shows bilateral pleural effusions
4. 1 and 3
5. All of the above

Reference as: Loftsgard T, Frost A, Evans D, Kolbet K. April 2015 critical care case of the month: half-sided light house. Southwest J Pulm Crit Care. 2015;10(4):159-70. doi: http://dx.doi.org/10.13175/swjpcc031-15 PDF

March 2015 Critical Care Case of the Month: It’s Not Always Sepsis

Dionne Morgan, MD 

Carolyn H. Welsh, MD 

University of Colorado and the Eastern Colorado Veterans Affairs Medical Center

Department of Medicine

Division of Pulmonary Sciences and Critical Care Medicine

Denver, CO

History of Present Illness

A 57-year-old man with multiple co-morbidities including diabetes mellitus presented with wet gangrene of the right foot and hypotension.  He had diabetic ketoacidosis and acute kidney injury. He was admitted to the medical intensive care unit, given intravenous fluids and treated with insulin therapy, piperacillin/tazobactam and vancomycin. Initial blood cultures grew Methicillin-resistant Staphylococcus aureus (MRSA). The podiatry service performed a right transmetatarsal amputation. Subsequently, he did well and was transferred to a medical floor for further care. 

Three weeks later, following resolution of the initial sepsis, he developed persistently high fevers with hemodynamic instability despite continued antibiotic therapy. He was transferred back to the MICU for presumed sepsis.

Past Medical History, Social History and Family History

The past medical history was significant for diabetes, hypertension, COPD, coronary artery disease and hepatitis C. He did not smoke nor drink alcohol. Family history was non-contributory.

Physical Examination

On readmission to the medical intensive care unit, the patient was noted to have a generalized maculopapular rash on both upper and lower extremities, torso, palms and soles of his feet, associated with facial and periorbital edema (Figure 1). There was no mucosal membrane involvement or lymphadenopathy.  He was also febrile to 104^o F, hypotensive to 80/50 mm Hg and icteric.

Figure 1. Image of rash.

Laboratory Studies

Initial labs showed elevated leukocyte count, BUN and creatinine with anion-gap metabolic acidosis but a normal liver enzyme profile. Repeat labs on readmission to the medical ICU were significant for severe leukocytosis, with marked eosinophilia, atypical lymphocytes on blood smear, acute transaminitis and hyperbilirubinemia.

Admission labs: White blood cell count (WBC) 29.9 x 1000 cells/μL. Eosinophils 0.0% (Normal 0.0 - 0.7%), AST 28 U/L, ALT 15 U/L, ALP 162 U/L, total bilirubin 0.2 mg/dL.

Labs on ICU readmission: White blood cell count (WBC) 35.7 x 1000 cells/ μL. Eosinophils 2.3% (Normal 0.0 -0.7%), AST 486 U/L, ALT 288 U/L, ALP 749 U/L, total bilirubin 4.3 mg/dL.

Which are components of the SIRS criteria? (click on the correct answer to proceed to the second of 4 panels)

1. Elevated respiratory rate
2. Hypothermia
3. Leukocytosis
4. Tachycardia
5. All the above

Reference as: Morgan D, Welsh CH. March 2015 critical care case of the month: it's not always sepsis. Southwest J Pulm Crit Care. 2015;10(3):105-11. doi: http://dx.doi.org/10.13175/swjpcc029-15 PDF

Ultrasound for Critical Care Physicians: Now My Heart Is Even More Full

Bilal Jalil, MD

Michel Boivin, MD

Division of Pulmonary, Critical Care and Sleep Medicine

University of New Mexico School of Medicine

Albuquerque, NM

A 49-year-old man with type 2 diabetes, intravenous drug abuse and heart failure presented to the emergency room with 2 weeks of progressively worsening chest pain, lower extremity swelling and shortness of breath. The patient was found to have an elevated troponin as well as brain natriuretic peptide and the absence of ischemic electrocardiogram findings. The patient was admitted to the medical ICU for hypoxic respiratory failure and shock of uncertain etiology. Clinically he seemed to be in decompensated heart failure and a bedside echocardiogram was performed (Figures 1 and 2).

Figure 1. Parasternal short axis view at the level of the aortic valve

Figure 2. Apical 4 chamber view.

What is the best explanation for the echocardiographic findings shown above? (Click on the correct answer for the explanation)

1. Atrial myxoma
2. Cardiac amyloidosis
3. Cardiac lymphoma
4. Takotsubo cardiomyopathy
5. Tricuspid valve endocarditis

Reference as: Jalil B, Boivin M. Ultrasound for critical care physicians: now my heart is even more full. Souhtwest J Pulm Crit Care. 2015;10(2):83-6. doi: http://dx.doi.org/10.13175/swjpcc020-15 PDF