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Further images of interesting central line complication…

April 19, 2014

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Last post was concerning an uncommon central line complication with the line passing into the mediastinum through the inferior brachiocephalic vein.  One astute observer asked for more information about the case, see the comments posted (very interesting fluoro experience with this type of  complication).  Here are some further images of the traversing the mediastinum very close to the aorta and the tip ends up near a pleural effusion on that side. 

Abberrent central line Aberrent Central line 1

Interestingly this patient had a vascular surgery consult.  The line actually passed through the IJ near the line insertion, tracked down the neck near the IJ and brachiocephalic,  and into the mediastinum.  The pleural effusion was from another process.  Fortunately the line was removed and no further problems were encountered. 

Unfortunately this was another team that placed the line so I don’t have information on the actual difficulty in placing the line, confirmation of venous flow once placed, etc. 

Thanks for the comments.

Author:  Russell Jones, MD

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Central line complication…

April 14, 2014

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Central line mishap 1

Central line mishap 2 Central line mishap 3 Central line mishap 4

Central lines are often necessary and performed quite frequently.  With frequent procedures sometimes we get comfortable performing them and we minimize possible dangers.  This case demonstrates, however, that there are real complications that can occur from our invasive procedures.  Thus it is important to weigh the risks and benefits.

This central line decided to go through the caudal portion of the brachiocephalic vein and into the mediastinum.  The first xray shows the end of the catheter kinked near the aortic root.  CT of the chest shows the distal tip of the catheter puncturing through the vein and into the mediastinum.  Obviously this is a very rare complication!

Image Contributor:  Aaron Hougham, MD

Author:  Russell Jones, MD

 

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Multiple masses chest..

April 3, 2014

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Late 20s male presents with shortness of breath…

Chest masses Chest masses CT

This Xray and CT show a phenomena called “Cannonball Metastases.”  This refers to innumerable descreet masses in the chest.  Two tumors are highly suspected in this case: renal cell carcinoma and choriocarcinoma.   Others that have a higher prediliction to multiple lung mets are prostate, endometrial, and synovial sarcoma (1). 

This patient ended up having a choriocarcinoma of the testes. 

Image Contributors:  Kevin Murphy, MD and Mary Bing, MD

Author:  Russell Jones, MD

References:

1.  Knipe H, Bickle I, et al.  Cannonball Metastases. www.radiopaedia.org

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Abdominal pain…

March 24, 2014

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Patient had RLQ abdominal pain, we obtained a CT looking for appendicitis:

Pill frags 1

The patient has multiple, radiodense objects throught the small bowel.  Upon further history this patient was taking multiple calcium and iron supplement pills a day. 

Author:  Russell Jones, MD

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Device for spasticity…

March 11, 2014

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Here is a CT (with scout film) showing a not-to-uncommon device placed in the abdominal wall:

Baclofen 1 Baclofen 2 Baclofen 3

This is an example of an intrathecal pump, commonly used to deliver baclofen.  The first image shows the pump tubing coursing on the abdominal wall, into the thecal space (inserting just lateral to the spinous process of the lumbar vertebrae).  The second image shows a crossection where the pump is located in the abdominal musculature.  The scout film gives you a good idea how big these pumps are.  They have a reservoir port for percutaneous refilling of the baclofen and they can be interrogated for functioning and changing settings. 

Complications of these can include pump failure, baclofen running empty, tubing kink or breakage, and infection/hematoma, and a cerebrospinal fluid leak at the site of insertion.

Author:  Russell Jones, MD

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Pediatric back pain (answer)…

March 7, 2014

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Several days ago I presented an early teenage patient with back pain:

ES of spine 1 ES spine 2

This patient has an osteolytic lesion at T11 which was later biopsied and found to be Ewing’s Sarcoma of the spine.  Roughly 10% of Ewing’s Sarcoma will primarily present in the spinal column.  Pediatric spinal column tumors are very rare but should be kept on the differential diagnosis of pediatric back pain.  Unlike adults, pediatric patients rarely present to the ED with the chief complaint of back pain.  Pyelonephritis and acute trauma are the leading pathology but malignancy should be explored if the clinical scenario is worrisome (weight loss, night sweats, neurologic signs, or unrelenting pain over weeks/months, central spinal tenderness). 

For more information on Ewing’s Sarcoma of the spine here is a summary article from Skeletal Radiology:

Ilaslan H, et al.  Primary Ewing’s sarcoma of the vertebral column.  Skeletal Radiol 2004 Sep; 33 (9): 506-13.

Author:  Russell Jones, MD

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Pediatric back pain…

March 3, 2014

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Early teen presents with back pain for several months…

ES of spine 1

ES spine 2

This thoracic spine series shows a loss of vertebral height at T11 and an indistinct right pedicle of T11.  What could cause this in an early teenager?  There was no history of trauma.

Answer to follow.

Author:  Russell Jones, MD

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Heart in the Heart…Happy Valentine’s Day

February 14, 2014

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This patient had a transvenous pacemaker placed for severe bradycardia:

Heart in heart

 

This patient has a transvenous pacing wire which decided to loop around the right side of the heart.  It was working though!  Happy Valentine’s Day.

Image contributor:  James Chenoweth, MD

Author:  Russell Jones, MD

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Should’ve worn eye protection…

February 8, 2014

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This patient was working on cutting copper wire without eye protection:

Ocular FB

 

On exam the patient had a small laceration just medial to the limbus in the scleral portion of the eye, no anterior chamber or corneal involvement.  He had a positive Seidel test (fluorcein stains vitreous green under blue light.  As the vitreous leaks out you can see green tinged fluid leaking from the area of concern). 

On CT there is a metallic fragment found in the posterior chamber indicative of a penetrating copper foreign body.  This is an ocular emergency and should prompt immediate evaluation by an ophthalmologist!

Author:  Russell Jones, MD

 

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Classic Xray…

February 3, 2014

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This patient presents with a peritoneal abdomen on exam:

Free air 1 Free air 2 

This is a great abdominal series showing free peritoneal air.  This is a sign of gastric, bowel, or colonic perforation and is a surgical emergency. 

The abdominal series has limited utility in the ED due to poor sensitivity and specificity for most intraabdominal pathology.  However, in a patient with a peritoneal abdomen it is a quick and cost-effective means of screening for free air.  This patient was emergently taken to the operating room for exploratory laparotomy. 

Author:  Russell Jones, MD

Image Contributor:  Ali Naqvi, MD

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