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WWWTP #24 Answer…

July 1, 2015

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Trauma patient came in to the ED:

CXR 1

What’s Wrong With This Picture?

The patient’s chest tube is not inserted far enough.  It is also a bit high residing between ribs 3-4.

Chest tubes have a side port and a distal port for suctioning fluids, air from the pleural space.  There is a radiopaque line seen on the tube that is interrupted at the side port (see magnified image).  In this case the radiograph shows that the side port is subcutaneous and not inserted all the way into the pleural space.  The chest tube needs to be replaced!

Author:  Russell Jones, MD

Image Contributor:  David Barnes, MD

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What valve has been replaced?

December 16, 2014

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Here is a patient with a cardiac valve…he did not know which valve was replaced.  Which one is it?

Valve AP Valve Lat

RadDaily.com helps with this dilemma:

http://www.raddaily.com/whitepaperarticle.php?articleTitle=Cardiac+Valves:+Assessment+and+Identification

If we apply the rules from RadDaily.com to our patient, it appears he has an aortic valve:

Valve Lat EditedValve Lat

Valve AP editValve AP

AV = Aortic Valve*

TV = Tricuspid Valve*

MV = Mitral Valve*

PV = Pulmonic Valve*

*These are anticipated locations.  The locations could be altered if the patient has anatomic variations such as chamber enlargement, cardiac rotation, etc.

RadDaily also has additional information using flow directional clues from the shape of the valves.  Check it out!

Author:  Russell Jones, MD

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What valve has been replaced?

December 10, 2014

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Here is a patient with a prosthetic cardiac valve…he did not know which valve was replaced.  Which one is it?

Valve AP Valve Lat

Answer to follow.

Author:  Russell Jones, MD

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How to identify a cardiac rhythm device with CXR…

September 25, 2014

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How many times have you had trouble with figuring out what type of cardiac device (e.g. pacemaker/defibrillator) a patient has implanted?  A patient presented to our ED with chest pain, palpitations.  He did not have his device card with them, no prior visits to our ED, and did not know the manufacturer of the device.  How do you decide which company to call for interrogation?

Here is an article I found with radiologic characteristics of devices that can help identify which company produced the device.  It has a great identification algorithm they coined the CaRDIA-X algorithm:

http://www.ianchristoph.com/physician-resources-2/device_id.pdf

There are 5 major manufacturers currently:  Medtronic, Boston Scientific, St. Jude, Biotronik, and Sorin Group.  Each device manufactured by these companies have certain differentiating characteristics of can shape, battery shape, alphanumeric codes, capacitor shadows, coil types, etc.  Turns out you can identify the manufacturer using the device characteristics on chest X-ray relatively easily.

In the case I was describing above the patient had an easily identifiable Medtronic device and we were able to get it interrogated.  Our ED now has the algorithm posted at our doctor’s station so we can utilize it for device identification.

Author:  Russell Jones, MD

References

Jacob S et al.  Cardiac Rhythm Device Identification Algorithm Using X-Rays: CaRDIA-X.  Heart Rhythm 2011; 8(6): 915-922.

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What are these devices? Answer…

July 31, 2014

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Question earlier this week:  “There are two devices entering the mediastinal structures from below…what are they?”

IABP 2

iabp-2

There are a bunch of devices on this radiograph.  Here they are by color:

1.  Orange arrow:  A Swan-Ganz catheter coming up from the femoral vein

2.  Red arrow:  Intra-aortic balloon pump coming up from the femoral artery

3.  Green arrow:  External monitor cables extending to the various monitor points on the patient externally

4.  Blue arrow: Dialysis catheter coming from the right internal jugular vein

Admittedly, this is not your usual ED-based radiograph.  This patient was presented with a STEMI and in cardiogenic shock.  This was a radiograph obtained later in the cardiac ICU after coronary intervention.  The Swan-Ganz catheter is unclear if it is in proper position (pulmonary artery).  Usually Swan-Ganz catheters (AKA pulmonary artery catheters) are placed from the superior circulation and loop into the pulmonary artery.  This was placed under fluoroscopy while performing a coronary artery intervention in the cath lab; I’m not sure where the tip is located based on this radiograph.

Author:  Russell Jones, MD

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What are these devices?

July 28, 2014

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There are two devices entering the mediastinal structures from below…what are they?

IABP 2

 

Answer to follow!

Author:  Russell Jones, MD

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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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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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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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