EM REMS

This patient presented with chest pain, we obtained a chest xray:

Overlying the cardiac silhouette is a pair of wires for an epicardial pacemaker.  The patient had a coronary artery bypass graft procedure several years ago and required an epicardial pacemaker in the postoperative period.  The leads were left in and the pacemaker is now gone.  The wires are unique to this type of pacemaker as they have the button-like attachment to the epicardial surface.  They are typically used in the postoperative period and are indicated for temporary use; their function deteriorates in a matter of days to weeks (1).

The wires were somewhat confusing to our treatment team until we reviewed his chart and did a little internet searching!

Author:  Russell Jones, MD

References

1.  Batra AS, Seshadri B.  Postoperative temporary epicardial pacing:  When, how, and why?  Ann Ped Card 2008, 1(2): 120-125. 

I had a patient come in the other day with an interesting Chest Xray:

This patient has a lot of hardware in his chest.

1. He has a tracheostomy present
2. Surgical clips can be seen on the aortic arch
3. This is an artificial aortic valve
4. Sternal wires for closure after his aortic valve replacement

Here is a link to an interesting image the New England Journal of Medicine published in 2005 that shows a person with replacements in all 4 valves:

Four Valver!

Author:  Russell Jones, MD

References

Bijl M, van den Brink R.  Images in Clinical Medicine:  Four Artificial Heart Valves.  N Engl J Med 2005; 353: 712

We’ve all had them…the really, really bad GI bleeder.  Thus man came in peri-code.  He was resuscitated with massive-transfusion to somewhat clinically stable.  After NG tube initially showed over a liter of blood return it stopped, couldn’t be lavaged or suctioned, and his abdomen started distending over the course of the next 1/2 hour.  We decided to get a CT scan to evaluate the distension and this is what was found:

The abdominal CT with contrast shows very large varicies extending into the stomach!  His stomach has several fluid densities consistent with hematoma, blood, and an area concerning for active exstravasation.  On the coronal image you can also see some dependent ascites around the liver.  The distal portion of the nasogastric tube is thought to have been obstructed by the large hematoma in his stomach.

The patient ended up improving with octreotide and correcting his INR of 3.5.  He had an esophagogastroduodenoscopy (EGD) which confirmed varicies and several were banded.

WARNING:  CT abdomen is not a usual imaging modality for GI bleeders.  We obtained imaging because the patient had increasing distension and abdominal pain.  We wanted to rule out aortic pathology, mesenteric ischemia, hemorrhagic malignancy, gastric perforation, and other pathology that sometimes can be associated with GI bleeding.  I don’t advocate CT imaging in most GI bleeders.

Author:  Russell Jones, MD

This patient presented with nausea, vomiting, diffuse abdominal pain, and no bowel movement for a couple days.

This patient has a history of Ogilvie syndrome and this abdominal xray helps support this diagnosis.  Ogilvie syndrome is an acute pseudo-obstruction of the GI tract without a mechanical obstruction.  Xray will often show massive (>10cm) dilitation of the colon, usually on the cecal side.  This patient’s cecum measures out to be 21 cm!

Brief summary of Ogilvie Syndrome courtesy of Wikipedia:

Ogilvie

Author:  Russell Jones, MD

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

Here is an MRI head on a patient with a headache and newly diagnosed brain mass:

This is a T2 weighted MRI.  T2 weighting is particularly good at showing edema.  Simple fluid enhances and appears bright on the image.  Above you can see the tumor arising near the peripheral parietal area with a good amount of surrounding bright fluid consistent with edema.  Note that the edema shows up similar to the patient’s normal CSF in the ventricles. 

If you add contrast to the study (gadolinium) and T1 weight the image this is what you’ll see:

In T1 weighted imaging simple fluid is darker but in this case the tumor outlines very well with gadolinium.  This imaging is particularly good at picking up smaller tumors without large amounts of surrounding edema.  In this case several other smaller lesions were easily identified with T1 gadolinium imaging including one seen in the midbrain:

These turned out to be a metastatic lesions likely from the lung.  Metastases are the most common clinically important brain malignancies found outside of the pediatric population (the exact incidence of non-clinically apparent. 

Author:  Russell Jones, MD

An elderly patient presented with abdominal pain for a week.  The patient had peritoneal signs on exam and thus xray imaging was pursued (see discussion below):

Image 1

Image 2

Image 3

This is an acute abdominal series showing free intraperitoneal air in the right upper quadrant.  Notice that it cannot be determined if the patient has free air on the supine view (Image 1).  This is because the air is layering to the anterior portion of the peritoneal cavity.  In order to reveal air in the peritoneum, one must layer it to one of the sides (Image 2 – patient is laying on their left side and the air flows to the right upper quadrant) or upright (Image 3 – patient is upright and the air layers under the diaphragm, in this case the right side). 

I like the acute abdominal series to look for free air in the setting of a highly concerning exam.  You can also just do an upright chest xray.  They are quick and if free air is found it will likely be a study that will change the patient’s course; surgery will in most cases take the patient to the operating room with just an xray for exploratory laparotomy.  In our case, however, surgery was tied up for a bit and this allowed an extra 1/2 hour ED stay, I pursued non-contrast CT to further identify what was going on:

Image 4

Image 5

This CT shows findings highly concerning for a perforated duodenal ulcer.  In Image 4 you can see the air just above the liver edge anteriorly along with free intraperitoneal fluid layering on the side of the liver and spleen.  She also has an aortic aneurysm.  Image 5 shows an area of free air and stranding near the distal duodenum.  Laparotomy revealed a perforated duodenal ulcer, the aortic aneurysm was incidental. 

Author:  Russell Jones, MD

This patient came in septic with hypotension, tachycardia, obtunded mental status.  A decubitus ulcer was noted stage III with surrounding crepitus and erythema.  There is an impressive amount of gas extending up the fascial planes in the upper left leg, gluteal area, extending through the sciatic foramen into the pelvic cavity.  This is consistent with necrotizing fasciitis and this extent of involvement has a very poor prognosis.  The source was likely a sacral decubitus ulcer. 

Author:  Russell Jones, MD.

…but probably most of us have!  One of the senior residents gave me this Chest Xray on a person that came in with cardiac arrest:

This Chest Xray demonstrates a large pneumothorax on the right side with tension phenomena.  Tension Pneumothorax is when the air trapped in the pleural space places pressure on the mediastinal structures and you see a shift of the mediastinum in the opposite direction.

Physiologically this means that the anatomy has changed and blood flow back to the central circulation is limited by not only mechanical obstruction but increased intrathoracic pressure.

After thoracostomy:

Remember, tension pneumothorax is one of the 5h’s and 5T’s that cause cardiac arrest.  However, its unclear if this is a post CPR pneumothorax or if this was the cause of the cardiac arrest.  You can see some deformities suspicious for rib fractures mid-way down the right lung fields.  There was no indication of trauma in the patient’s presentation so these may be old or a complication of chest compressions…this could be a source of pneumothorax as well as the positive-pressure from endotracheal intubation.  Incidentally, the chest tube is inserted slightly far with kinking in the upper lung but it appears to be working with reexpansion and relief of the tension phenomena.

Author:  Russell Jones, MD

Image Contributor:  Ryan Hunt, MD