Ultrasound for Critical Care Physicians: Now My Heart Is Still Somewhat Full

Krystal Chan, MD

Bilal Jalil, MD

Department of Internal Medicine

University of New Mexico School of Medicine

Albuquerque, NM USA

A 48-year-old man with a history of hypertension, intravenous drug abuse, hepatitis C, and cirrhosis presented with 1 day of melena and hematemesis. While in the Emergency Department, the patient was witnessed to have approximately 700 mL of hematemesis with tachycardia and hypotension. The patient was admitted to the Medical Intensive Care Unit for hypotension secondary to acute blood loss. He was found to have a decreased hemoglobin, elevated international normalized ratio (INR), and sinus tachycardia. A bedside echocardiogram was performed.

Figure 1. Apical four chamber view of the heart.

Figure 2. Longitudinal view of the inferior vena cava entering into the right atrium.

What is the best explanation for the echocardiographic findings shown above? (Click on the correct answer for an explanation and discussion)

1. Atrial Fibrillation
2. Atrial Myxoma
3. Cardiac Lymphoma
4. Tricuspid Valve Endocarditis
5. Tumor Thrombus

Cite as: Chan K, Jalil B. Ultrasound for critical care physicians: now my heart is still somewhat full. Southwest J Pulm Crit Care. 2016;12(6):236-9. doi: http://dx.doi.org/10.13175/swjpcc054-16 PDF 

April 2016 Critical Care Case of the Month

Samir Sultan, DO

Banner University Medical Center Phoenix

Phoenix, AZ

Critical Care Case of the Month CME Information

Members of the Arizona, New Mexico, Colorado and California Thoracic Societies and the Mayo Clinic are able to receive 0.25 AMA PRA Category 1 Credits™ for each case they complete. Completion of an evaluation form is required to receive credit and a link is provided on the last panel of the activity. 

0.25 AMA PRA Category 1 Credit(s)™

Estimated time to complete this activity: 0.25 hours 

Lead Author(s): Samir Sultan, DO.  All Faculty, CME Planning Committee Members, and the CME Office Reviewers have disclosed that they do not have any relevant financial relationships with commercial interests that would constitute a conflict of interest concerning this CME activity.

Learning Objectives:
As a result of this activity I will be better able to:

1. Correctly interpret and identify clinical practices supported by the highest quality available evidence.
2. Will be better able to establsh the optimal evaluation leading to a correct diagnosis for patients with pulmonary, critical care and sleep disorders.
3. Will improve the translation of the most current clinical information into the delivery of high quality care for patients.
4. Will integrate new treatment options in discussing available treatment alternatives for patients with pulmonary, critical care and sleep related disorders.

Learning Format: Case-based, interactive online course, including mandatory assessment questions (number of questions varies by case). Please also read the Technical Requirements.

CME Sponsor: University of Arizona College of Medicine

Current Approval Period: January 1, 2015-December 31, 2016

Financial Support Received: None

History of Present Illness

The patient is a 22-year-old African-American man who was initially seen following a rapid response team called to the neonatal intensive care unit for a seizure. He was visiting his newborn child. The nurses described the seizure as tonic-clonic which resolved spontaneously without treatment before the rapid response team arrived.

Past Medical History, Family History and Social History

The patient has a past medical history of a brain aneurysm treated by coil embolization 2 years earlier. He had no complications of the embolization including seizures. Family history is unremarkable. He smokes 1-2 cigars per day but does not drink alcohol.

Physical Examination

He was drowsy when initially seen but the drowsiness resolved in about 5 minutes. The physical examination was unremarkable and there were no focal neurologic signs.

What should be next? (Click on the correct answer to proceed to the second of seven panels)

1. CT scan of the head
2. Phenytoin administration
3. Metabolic screening (BUN, glucose and electrolytes)
4. 1 and 3
5. All of the above

Cite as: Sultan S. April 2016 critical care case of the month. Southwest J Pulm Crit Care. 2016 Apr;12(4): . doi: http://dx.doi.org/10.13175/swjpcc033-16 PDF 

March 2016 Critical Care Case of the Month

Theo Loftsgard APRN, ACNP

Joel Hammill APRN, CNP

Mayo Clinic Minnesota

Rochester, MN USA

Critical Care Case of the Month CME Information

Members of the Arizona, New Mexico, Colorado and California Thoracic Societies and the Mayo Clinic are able to receive 0.25 AMA PRA Category 1 Credits™ for each case they complete. Completion of an evaluation form is required to receive credit and a link is provided on the last panel of the activity. 

0.25 AMA PRA Category 1 Credit(s)™

Estimated time to complete this activity: 0.25 hours

Lead Author(s): Theo Loftsgard APRN, ACNP.  All Faculty, CME Planning Committee Members, and the CME Office Reviewers have disclosed that they do not have any relevant financial relationships with commercial interests that would constitute a conflict of interest concerning this CME activity.

Learning Objectives:
As a result of this activity I will be better able to:

1. Correctly interpret and identify clinical practices supported by the highest quality available evidence.
2. Will be better able to establsh the optimal evaluation leading to a correct diagnosis for patients with pulmonary, critical care and sleep disorders.
3. Will improve the translation of the most current clinical information into the delivery of high quality care for patients.
4. Will integrate new treatment options in discussing available treatment alternatives for patients with pulmonary, critical care and sleep related disorders.

Learning Format: Case-based, interactive online course, including mandatory assessment questions (number of questions varies by case). Please also read the Technical Requirements.

CME Sponsor: University of Arizona College of Medicine

Current Approval Period: January 1, 2015-December 31, 2016

Financial Support Received: None

History of Present Illness

A 58-year-old man was admitted to the ICU in stable condition after an aortic valve replacement with a mechanical valve.

Past Medical History

He had with past medical history significant for endocarditis, severe aortic regurgitation related to aortic valve perforation, mild to moderate mitral valve regurgitation, atrial fibrillation, depression, hypertension, hyperlipidemia, obesity, and previous cervical spine surgery. As part of his preop workup, he had a cardiac catheterization performed which showed no significant coronary artery disease. Pulmonary function tests showed an FEV1 of 55% predicted and a FEV1/FVC ratio of 65% consistent with moderate obstruction.

Medications

Amiodarone 400 mg bid, digoxin 250 mcg, furosemide 20 mg IV bid, metoprolol 12.5 mg bid. Heparin nomogram since arrival in the ICU.

Physical Examination

He was extubated shortly after arrival in the ICU. Vitals signs were stable. His weight had increased 3 Kg compared to admission. He was awake and alert. Cardiac rhythm was irregular. Lungs had decreased breath sounds. Abdomen was unremarkable.

Laboratory

His admission laboratory is unremarkable and include a creatinine of 1.0 mg/dL, blood urea nitrogen (BUN) of 18 mg/dL, white blood count (WBC) of 7.3 X 10⁹ cells/L, and electrolytes with normal limits.

Radiography

His portable chest x-ray is shown in Figure 1.

Figure 1. Portable chest x-ray taken on admission to the ICU. 

What should be done next? (Click on the correct answer to proceed to the second of five panels)

1. Bedside echocardiogram
2. Diuresis with a furosemide drip because of his weight gain and cardiomegaly
3. Observation
4. 1 and 3
5. All of the above

Cite as: Loftsgard T, Hammill J. March 2016 critical care case of the month. Southwest J Pulm Crit Care. 2016;12(3):81-8. doi: http://dx.doi.org/10.13175/swjpcc018-16 PDF

Ultrasound for Critical Care Physicians: 50 Ways to Line Your Liver

Seth Skiles ACNP

Theresa Heynekamp MD MPH

Division of Pulmonary, Critical care and Sleep Medicine,

University of New Mexico School of Medicine

Albuquerque, NM USA

A 54-year-old man with a past medical history significant for traumatic brain injury and aspiration pneumonia presented with hypoxic respiratory failure secondary to foreign body aspiration.

On presentation, the patient was found to be hypoxic and tachypneic, requiring endotracheal intubation and mechanical ventilation. Bronchoscopy was performed with removal of extensive food particles throughout both lungs. The patient subsequently developed sepsis secondary to aspiration pneumonia.  He became hypotensive, requiring central venous catheter placement for vasopressor therapy. A right subclavian central line was attempted under ultrasound guidance. A beside ultrasound was subsequently performed (Video 1).

Video 1. Sagittal view of the liver and heart at the level of the mid-abdomen and slightly right of mid-line.

What does the video obtained of a longitudinal view of the IVC at the level of the liver demonstrate? (Click on the correct answer for a discussion)

1. Endocarditis
2. Guidewire in the hepatic vein
3. Hemopericardium
4. Pneumothorax

Cite as: Skiles S, Heynekamp T. Ultrasound for critical care physicians: 50 ways to line your liver. Southwest J Pulm Crit Care. 2015;11(5):235-7. doi: http://dx.doi.org/10.13175/swjpcc144-15 PDF

September 2015 Critical Care Case of the Month: If You Don't Look, You Won't Find

Robert A. Raschke, MD

Banner University Medical Center

Phoenix, AZ

 History of Present Illness

A 55-year-old woman was transferred from Mexico emergently for acute cardiomyopathy. On the day of admission, she went for a 45-min “exercise” walk and cleaned her house. While taking a shower, she suffered an acute onset of dyspnea with nausea and vomiting and possibly a small amount of hematemesis. She appeared seriously ill to her husband, who took her blood pressure (198/?) and pulse (90) and rushed her to a local medical facility.  There, she was found to have severe pulmonary edema, and a troponin of 11.  Her echo showed inferior wall motion abnormality with an ejection fraction of 35%.  However, coronary catheterization showed normal coronaries.  She was treated with oxygen, furosemide, labetolol and enoxaparin and transferred emergently to Banner-University Medical Center. 

Past Medical History, Family History and Social History

The patient reported intermittent "spells" since May. These typically occurred upon  lying down in bed and were characterized by her as a feeling of “numbness” or tingling  which ascends from her chest to her head associated with palpitations and a feeling of  “desperation”, typically relieved after a few minutes upon getting up out of bed.

She had a history of hypertension and had been on losartan but this was discontinued a few months previously because of the onset of orthostatic dizziness. She also has a history of hypothyroidism and is taking synthroid. She was treated three times in the last 6 month for amoebiasis. She is a medical missionary to La Paz, Mexico and has recently traveled to Bolivia and Guatemala.

Review of Systems

She has had some night sweats, coughing with deep inspiration, and some slight hemoptysis. She did have a headache one month previously at 7000 ft elevation while in Guatemala.

Physical Examination

• She appears in moderate distress. Her vital signs are normal other than a mild tachycardia.  
• She does have rales on auscultation of her lungs.
• The remainder of the physical examination was unremarkable.

Radiography

A portable chest radiograph is performed (Figure 1).

Figure 1. Admission portable chest radiograph.

Laboratory evaluation

Her CBC shows a normal hemoglobin and hematocrit but with an elevated white blood cell count of 26,500 cells/mcL with a left shift. Admission electrolytes and blood sugar are within normal limits.

What additional procedures/testing are indicated? (Click on the correct answer to proceed to the second of four panels)

1. Blood cultures
2. Echocardiogram
3. Electrocardiogram
4. NT-pro-brain natriuretic peptide (NT-pro-BNP)
5. All of the above

Reference as: Raschke RA. September 2015 critical care case of the month: if you don't look, you won't find. Southwest J Pulm Crit Care. 2015;11(3):97-102. doi: http://dx.doi.org/10.13175/swjpcc113-15 PDF 

Ultrasound For Critical Care Physicians: Neutropenic Patient With Fever and Shortness of Breath

Erik Kraai MD

Michel Boivin MD

Division of Pulmonary / Critical Care and Sleep

University of New Mexico

Albuquerque, NM

A 63 year old female with a history of acute myelogenous leukemia presents with shortness of breath, fever and hypotension to the ICU. She is in septic shock on norepinephrine, and has been treated on the oncology unit with vancomycin, cefepime, acyclovir and voriconazole. She has been neutropenic for 1 month. The patient develops a progressive right lower chest opacity. This opacity has progressed in spite of antibiotics and antifungals. The portable AP chest radiograph is presented below (Figure 1). 

Figure 1. Portable AP of chest.

An ultrasound of the right chest was performed for further evaluation of the opacity (figure 2). 

Figure 2. Ultrasound of right hemithorax.

Question: What pathology does the ultrasound reveal in the right hemithorax? (Click on the correct answer to proceed to the next panel)

1. Air filled cavity
2. Chest wall abscess
3. Fractured ribs
4. Pleural effusion and suspected empyema
5. Simple consolidation

Refernece as: Kraai E, Boivin M. Ultrasound for critical care physicians: neutropenic patient with fever snd shortness of breath. Southwest J Pulm Crit Care. 2014;8(6):330-3. doi: http://dx.doi.org/10.13175/swjpcc073-14 PDF