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

November 2015 Critical Care Case of the Month

Samir Sultan, DO

Banner University Medical Center Phoenix

Phoenix, AZ

 History of Present Illness

A 39-year-old Caucasian woman was admitted to the ICU with worsening dyspnea and increasing oxygen requirements. Her lips turned blue with minimal activity. She was admitted to another hospital 5 months earlier with pneumonia. At discharge she was placed on oxygen. At follow-up with her pulmonologist, she was diagnosed with sleep apnea.

Past Medical History, Family History, Social History

• She has a history of an optic glioma at age 7 with resection followed by radiation therapy and development of panhypopituitarism.
• Liver cirrhosis diagnosed in 2014 with presentation of hematemesis.
• Type 2 diabetes mellitus
• Denies tobacco, ethanol, or illicit drug use.
• There is a family history of diabetes and liver cirrhosis

Physical Examination

• Vital signs:110 / 86, HR 97, RR 16, 88% on 6 liter O2
• General: obese female (BMI 35) in no apparent distress
• Chest: Clear to auscultation bilaterally
• Cardiovascular: regular rate without murmur or rub
• The remainder of the physical exam is normal  

Radiography

      A chest x-ray was interpreted as normal.

Laboratory

• CBC: hemoglobin 13.8 gm/dL, WBC 7 X 103 cells/microliter with a normal differential
• Basic metabolic panel: Na⁺ 132 mEq/L, K⁺ 4 mEq/L, Cl^- 100 mEq/L, HCO3^- 22 mEq/L, glucose 150 mg/dL.
• Arterial blood gases (ABGs): PaO₂ 35 mm Hg, PaCO₂ 37 mm Hg, pH 7.43

Which of the following is/are not possible cause(s) of hypoxemia in this patient? (Click on the correct answer to proceed to the second of six panels)

1. Decreased diffusion (alveolar capillary block)
2. Ventilation-perfusion mismatch
3. Hypoventilation
4. 1 and 3
5. All of the above

Cite as: Sultan S. November 2015 critical care case of the month. Southwest J Pulm Crit Care. 2015;11(5):209-15. doi: http://dx.doi.org/10.13175/swjpcc137-15 PDF

Ultrasound for Critical Care Physicians: The Martian

Jawad Abukhalaf, MD

Michel Boivin, MD

Division of Pulmonary, Critical care and Sleep Medicine,

University of New Mexico School of Medicine

Albuquerque, NM USA

A 54 year old male with a past medical history significant for granulomatosis with polyangiitis (formerly known as Wegener’s granulomatosis) and chronic kidney disease presented with hemoptysis and chest pain.

On presentation, he was found to have a 10 cm right middle lobe cavitary lesion and was subsequently treated with high dose steroids, antibiotics and antifungals based on bronchoalveolar lavage results. On day 9 of his hospital stay the patient was found to have bilateral lower extremity deep venous thromboses that were treated with intravenous heparin. On day 11 of his stay, the patient started experiencing lower abdominal pain and hypotension. The patient was resuscitated with saline. Bedside ultrasonography was performed.

Figure 1. Transverse lower abdominal ultrasound in the pelvis.

What does the transverse view of the lower abdomen (just above the symphysis pubis) demonstrate? (Click on the correct answer for an explanation)

1. Abdominal wall hematoma
2. Distended bladder
3. Horseshoe kidney
4. Psoas hematoma

Cite as: Abukhalaf J, Boivin M. Ultrasound for critical care physicians: the martian. Southwest J Pulm Crit Care. 2015;11(4):186-8. doi: http://dx.doi.org/10.13175/swjpcc135-15 PDF 

October 2015 Critical Care Case of the Month: A Moldy But Gooey

Jennifer M. Hall, DO

Banner University Medical Center Phoenix

Phoenix, AZ

History of Present Illness

A 45-year-old man with a history of a kidney transplant in 2011 was admitted with subjective fevers, nausea, abdominal pain, chest pain and recurrent renal failure. Cardiac workup was negative for ischemia and intermittent hemodialysis was initiated. CT of chest and abdomen was significant for a new cavitary pulmonary lesion. Leading up to this admission, he had been on immunosuppressive agents including tacrolimus, mycophenolate and prednisone, and the day of presentation had been doing quite well, actually was bear hunting in the mountains near Flagstaff, Arizona.

Past Medical History

• Donor kidney transplant in 1999, which failed in 2011, prompting a second kidney transplant
• Failed pancreas transplant
• Coronary artery disease, with percutaneous cardiac intervention in 2001
• Diabetes mellitus type I
• Chronic anemia
• History of total parathyroidectomy
• History of C5-C7 cervical fixation

Physical Examination

• Vital signs stable
• Appeared to be pale, no apparent distress
• Cardiac exam unremarkable
• Chest exam with fine crackles in left base / otherwise clear
• Abdomen slightly tender in left lower quadrant, but without guarding, rebound or peritoneal signs; small dime-sized area of ecchymosis, where lovenox injections had been administered
• No peripheral edema or clubbing

Laboratory Evaluation

• WBC 17,900 cells/mcL with 96% segmented neutrophils, hemoglobin 8.9 g/dL(after transfused 2 units prior to transfer), PLT 232,000 cells/mcL,
• INR 1.3
• Blood urea nitrogen (BUN) 74 mg/dL, serum creatinine 2.32 mg/dL, electrolytes within normal limits, albumin 3.2 g/dL, aspartate aminotransferase (AST) 24 IU/L, alanine transaminase (ALT)81 IU/L.
• NT-proBNP 6841 pg/ml (normal < 300 pg/ml)
• Hemoglobin A1C 7.2%
• Lactate 0.7 mmol/L

Imaging

A thoracic CT scan was performed (Figure 1).

Figure 1. Panels A-D: representative static views from the CT scan in lung windows. Note the cavitary lesion in the right lung (red arrow), the right pleural effusion (blue arrow) and the left lower lobe consolidation (yellow arrow) with a pleural effusion. Lower panel: video of the thoracic CT scan in lung windows.

Which diagnosis is least likely in this patient’s differential diagnosis for the cavitary pulmonary lesion? (Click on the correct answer to proceed to the second of five panels)

1. Aspergillosis
2. Coccidioidomycosis
3. Invasive mucormycosis
4. Metastatic malignancy
5. Nocardiosis
6. Pulmonary Infarct

Cite as: Hall JM. October 2015 critical care case of the month: a moldy but gooey. Southwest J Pulm Crit Care. 2015;11(4):136-43. doi: http://dx.doi.org/10.13175/swjpcc130-15 PDF

Ultrasound for Critical Care Physicians: Shortness of Breath

Matthew JK Douglas, MD

David Verbunker, MD

Jarrod Mosier, MD 

Department of Emergency Medicine

Banner University Medical Center Tucson

University of Arizona

Tucson, AZ

Figure 1. Video of the right thoracic ultrasound (coronal).

An 85 year old woman with a history of congestive heart failure and diabetes presented to the emergency department with progressive shortness of breath. She had recently been discharged from another hospital where she had been admitted for several days for community acquired pneumonia. The patient was in respiratory distress on arrival with tachypnea, increased work of breathing, and hypoxia despite supplemental oxygen with a non-rebreather mask and she was subsequently intubated. ED point-of-care ultrasound was performed of the right hemithorax.

What does Figure 1 demonstrate? (Click on the correct answer for the second of two panels and an explanation)

1. Intravascular volume depletion
2. Normal lung aeration
3. Numerous B-lines
4. Pleural effusion and consolidation
5. Pneumothorax

Cite as: Douglas MJK, Verbunker D, Mosier J. Ultrasound for critical care physicians: shortness of breath. Southwest J Pulm Crit Care. 2015;11(3):112-3. doi: http://dx.doi.org/10.13175/swjpcc116-15 PDF