EM REMS

A recent patient who presented after choking on a peanut butter and jelly sandwich…

This was an interesting case because of the post-intubation conundrum we faced.  The patient came in peri-arrest from hypoxia, GCS was 3 with very poor respiratory effort and oxygen saturation of 60%.  Therefore we were unable to get a great respiratory exam prior to intubation.  Bag-valve mask ventilation with 100% oxygen did not improve the situation and the patient was very difficult to bag due to obviously increased airway pressure.  The intubation was very difficult and as we were checking for bilateral breath sounds post-intubation, we noticed none on the left side.  Capnography color change was good, no gastric sounds were heard, and moisture was in the tube.  Pulling back the endotracheal tube did not change the lack of left sided lung sounds.  The patient continued to be difficult to bag with hypoxia very slowly improving from initial saturations in the 60s now to the mid-70s.  At this point all of our heart rates were around 150 and we had that sinking feeling that occurs when oxygenation doesn’t improve after intubation.

For a few minutes we were concerned about pneumothorax on the left side.  As you can tell from the xray our external landmarks such as tracheal deviation, jugular venous distention were severely limited by body habitus.  Bedside ultrasound using the linear probe was limited as well and no lung-sliding was visualized.  We basically couldn’t identify what we were seeing on ultrasound (later we found out the lung was completely collapsed and we may have been seeing diaphragm, heart, and non-aerated lung).  In the heat-of-the-moment the ED treatment team was perplexed on how to rule out a tension pneumothorax in this situation.

Luckily the patient’s oxygenation creeped above 90% and the patient didn’t have any blood pressure problems.  We took a deep breath, relaxed, and made the decision to obtain the above portable chest xray before performing empiric thoracostomy.  This turned out to be the correct decision as she had a complete obstruction of the left mainstem bronchus from aspiration of a peanut-butter sandwich.  CT chest (above) shows the obstruction at the level of the carina with collapse of the left lung.  Bronchoscopy was performed and a large amount of peanut butter, jelly, and sandwich fragments were removed with improvement in the patient’s chest xray post-procedure.

Moral of the story:  not all patients have pneumothorax or a malpositioned endotracheal tube when lung sounds are absent.

A brief alternative differential diagnosis when a patient has absent lung sounds on one side:

1. Mainstem bronchus obstruction or compression
2. Diaphragmatic hernia
3. Large pleural effusion
4. History of pneumonectomy

I’ve noticed a trend in ED training toward increased reliance on bedside ultrasound.  It is important to realize that if you are going to use ultrasound in the resuscitation decisions such as this, make sure that you are seeing something that reliably indicates the pathology you are seeking to correct.  We did not see signs that supported or refuted pneumothorax and thus the ultrasound was non-diagnostic.  I apologize for not having the ultrasound images.  We forgot to save them as we all had that panicked feeling when you’ve intubated someone and their pulse ox isn’t improving very fast!

Author:  Russell Jones, MD

I admire radiologists for their medical vocabulary.  I was sent some images from one of my colleagues the other day demonstrating “pneumorrhacis.”  Being a simple minded ER doc, I had to look it up.

Pneumorrhacis:  air in the intra or extra dural space (1).  For a good, concise summary of this rare phenomena see Radiopaedia.org:

Pneumorrhacis

This patient was a trauma patient with a pneumothorax as the source of the air.  You can see on the CT there is air everywhere!  Its basically dissecting fasical planes in the neck, chest, and abdominal wall in addition to the extradural space.

Here is a brief review article discussing pneumorrhacis from the European Spine Journal (2).  It is available on PubMed for free download or from this link:

Pneumorrhacis article

Author:  Russell Jones, MD

Image Contributor:  Steve Glocke, MD

References:

1.  Pneumorrhacis.  www.radiopaedia.org

2.  Oertel MF, Kornith MC, Reinges MH, et al.  Pathogenesis, diagnosis, and management of pneumorrhacis.  Eur Spine J (2006) 15 (Suppl. 5):S636–S643

I received an interesting CT Chest from one of our EM residents in a patient with SVC (Superior Vena Cava) syndrome.  The patient had a PORT in place with clot around the PORT occluding the SVC.  This is an interesting case with a couple common and a couple rare findings:

This is a complicated CT showing multiple findings:

A:  Good example of a right pleural effusion, large, seen on CT.  The patient also has a left sided effusion.

B:  Cross-section of the SVC showing the PORT cath and clot occluding the vessel

C:  Longitudal view of the SVC, again with PORT and clot

D:  The patient had the contrast injected from a right arm peripheral IV.  There are extensive collaterals in the arm and right chest with blood flow returning through these collaterals rather than traditional axillary vein to SVC.

E:  This view shows one of the collaterals actually connecting to the pulmonary vein.

Author:  Russell Jones, MD

Image Contributor:  Julie Phan, MD

One of my colleagues had a patient come in after a high-speed motor vehicle collision (MVC) and the patient turned out to have a blunt aortic injury (BAI).  Luckily she saved the images for EMREMS:

This first image is a portable AP Chest Xray.  There are multiple findings:

1.  The ETT tube is slightly high, this was corrected (see Post Intubation Eval)

2.  Chest tube is inserted in the left side and the patient has subcutaneous emphysema.  The chest tube could have been put in further but seems to be working.

3.  Notice the loss of normal contour of the aortic knob (aka “indistinct aortic knob”).

4.  The trachea is displaced to the patient’s right

5.  The upper mediastinum seems a little wide although not drastically.

6.  There is loss of the aortopulmonary window (AP window)

For comparison I have a normal AP Chest Xray and have arrows pointing to the normal AP window and aortic knob:

The patient’s Chest Xray is worrisome for traumatic aortic dissection.  Here is the patient’s Chest CT which confirms the diagnosis:

In the first image one can see a rough inner surface of the aorta indicating intimal disruption and hematoma.  A dissection flap can be seen in the second image.  Hematoma can be seen on both images surrounding the aorta and tracking in the mediastinum.

What are some other signs on Chest Xray that would get you worried about BAI? (Comments are encouraged)

Stay tuned in the future for a “Radiology Rules” 3X5 card with Chest Xray signs of BAI.

Author:  Russell Jones, MD

Image contributor:  Kendra Grether-Jones, MD