Archive | February, 2014

WWWTP #14 Answer….

February 25, 2014

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What’s Wrong With This Picture #14 Answer:

WWWTP 14

This elderly woman developed sudden shortness of breath and then had a hypoxic bradycardic cardiac arrest. Based on decreased breath sounds on the left and lack of lung sliding on ultrasound, she was needle decompressed (hence the subcutaneous air).  She was subsequently intubated.  A left subclavian central line was attempted since that was the side that was going to ultimately get a chest tube. Venous return was obtained, the wire passed smoothly, and once the line was in, blood was backing up in a pulsatile manner, suggesting arterial placement. It was left in place to tamponade the site.   This CXR confirmed arterial placement of the left sided line as it passes into the left side of the mediastinum at the aortic arch.

Here’s a short article on vascular repair of a SCA line placement:
http://www.hindawi.com/crim/vascular.medicine/2012/150343/

 Author:  Vivienne Ng, MD
 
Thanks go to Dr. Ng for the image and above discussion!
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WWWTP #14 (What’s Wrong With This Picture?)

February 20, 2014

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This is a critically ill patient with mutliple abnormalities on CXR.  Can you identify them?

WWWTP 14

 

What’s Wrong With This Picture?  Answer to follow…

Author:  Vivienne Ng, 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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