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Critical Care

Last 50 Critical Care Postings

(Click on title to be directed to posting, most recent listed first, CME offerings in Bold)

July 2019 Critical Care Case of The Month: An 18-Year-Old with
   Presumed Sepsis and Progressive Multisystem Organ Failure 
An Observational Study Demonstrating the Efficacy of Interleukin-1 
   Antagonist (Anakinra) in Critically-ill Patients with Hemophagocytic
   Lymphohistiocytosis
Which Half Are You? Almost Half of Pediatric Oncologists and Intensivists
   Are Burnt Out……
Management of Refractory Hypoxemic Respiratory Failure Secondary to
   Diffuse Alveolar Hemorrhage with Venovenous Extracorporeal Membrane
   Oxygenation
Amniotic Fluid Embolism: A Case Study and Literature Review
April 2019 Critical Care Case of the Month: A Severe Drinking
   Problem
Ultrasound for Critical Care Physicians: An Unexpected Target Lesion
January 2019 Critical Care Case of the Month: A 32-Year-Old Woman
   with Cardiac Arrest
The Explained Variance and Discriminant Accuracy of APACHE IVa 
   Severity Scoring in Specific Subgroups of ICU Patients
Ultrasound for Critical Care Physicians: Characteristic Findings in a 
   Complicated Effusion
October 2018 Critical Care Case of the Month: A Pain in the Neck
Ultrasound for Critical Care Physicians: Who Stole My Patient’s Trachea?
August 2018 Critical Care Case of the Month
Ultrasound for Critical Care Physicians: Caught in the Act
July 2018 Critical Care Case of the Month
June 2018 Critical Care Case of the Month
Fatal Consequences of Synergistic Anticoagulation
May 2018 Critical Care Case of the Month
Airway Registry and Training Curriculum Improve Intubation Outcomes in 
   the Intensive Care Unit
April 2018 Critical Care Case of the Month
Increased Incidence of Eosinophilia in Severe H1N1 Pneumonia during 2015
   Influenza Season
March 2018 Critical Care Case of the Month
Ultrasound for Critical Care Physicians: Ghost in the Machine
February 2018 Critical Care Case of the Month
January 2018 Critical Care Case of the Month
December 2017 Critical Care Case of the Month
November 2017 Critical Care Case of the Month
A New Interventional Bronchoscopy Technique for the Treatment of
   Bronchopleural Fistula
ACE Inhibitor Related Angioedema: A Case Report and Brief Review
Tumor Lysis Syndrome from a Solitary Nonseminomatous Germ Cell Tumor
October 2017 Critical Care Case of the Month
September 2017 Critical Care Case of the Month
August 2017 Critical Care Case of the Month
Telemedicine Using Stationary Hard-Wire Audiovisual Equipment or Robotic 
   Systems in Critical Care: A Brief Review
Carotid Cavernous Fistula: A Case Study and Review
July 2017 Critical Care Case of the Month
High-Sensitivity Troponin I and the Risk of Flow Limiting Coronary Artery 
   Disease in Non-ST Elevation Acute Coronary Syndrome (NSTE-ACS)
June 2017 Critical Care Case of the Month
Clinical Performance of an Interactive Clinical Decision Support System for 
   Assessment of Plasma Lactate in Hospitalized Patients with Organ
   Dysfunction
May 2017 Critical Care Case of the Month
Management of Life Threatening Post-Partum Hemorrhage with HBOC-201 
   in a Jehovah’s Witness
Tracheal Stoma Necrosis: A Case Report
April 2017 Critical Care Case of the Month
March 2017 Critical Care Case of the Month
Ultrasound for Critical Care Physicians: Unchain My Heart
February 2017 Critical Care Case of the Month
January 2017 Critical Care Case of the Month
December 2016 Critical Care Case of the Month
Ultrasound for Critical Care Physicians: A Pericardial Effusion of Uncertain 
   Significance
Corticosteroids and Influenza A associated Acute Respiratory Distress 
   Syndrome

 

For complete critical care listings click here.

The Southwest Journal of Pulmonary and Critical Care publishes articles directed to those who treat patients in the ICU, CCU and SICU including chest physicians, surgeons, pediatricians, pharmacists/pharmacologists, anesthesiologists, critical care nurses, and other healthcare professionals. Manuscripts may be either basic or clinical original investigations or review articles. Potential authors of review articles are encouraged to contact the editors before submission, however, unsolicited review articles will be considered.

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Saturday
Mar022013

March 2013 Critical Care Case of the Month: Beware the Escargot

Allen R. Thomas, MD

Suresh Uppalapu, MD

Phoenix VA Medical Center

Phoenix, Arizona

 

History of Present Illness

A 29 year old woman presented to the Phoenix VA Medical Center with complaints of headache and diffuse generalized weakness most pronounced in the lower extremities. She also noted recent fecal and urinary incontinence, abdominal pain, back pain, numbness in the feet and a non pruritic skin rash on the trunk. Onset of symptoms was about 2 weeks prior to her presentation.  Since her symptoms began she had seen in multiple local emergency departments for these same complaints as they worsened and was discharged home in each case with suspected viral syndrome.

PMH, SH, FH

She had no allergies and her past medical history was only significant for post- traumatic stress disorder. She has had no major surgery in her life so far and her family history was not contributory to her current presentation. She smokes marijuana for recreational purposes and drinks alcohol socially. She was not taking any medications on regular basis.

She had been in the military until six months prior to her presentation and her service included tours in Alaska and Hawaii.  She had recently returned from Fiji.  During her stay in Fiji, she reported eating snails and other uncooked food as well as drinking unpurified water

Physical Exam

Vital signs on presentation- T 98.4°C, P 102 beats/min, R 18 breaths/min, BP150/78 mm Hg  O2 sat 97% on room air

She was awake, alert, and oriented. She had mild nuchal rigidity and left ptosis. Lungs were clear and her cardiac exam was normal. Abdominal exam showed diffuse tenderness to palpation with hypoactive bowel sounds. Strength was 5/5 in the upper extremities, 4/5 on the right lower extremity, and 3/5 left lower extremity.  Sensation was Intact throughout.  Deep tendon reflexes were 1+.  Exam was thought to be somewhat limited due to poor effort.

Laboratory findings

White blood cell count was 12,400 mm3 with 75% neutrophils and 8% eosinophils.

Hemoglobin- 13.8 mg/dl; Hematocrit-41%; Platelet count was 317,000/mm3

Complete metabolic profile was normal.

CPK was elevated at 696 IU/Liter.

Radiology 

Chest x-ray showed some blunting of the left costophrenic angle with clear lung fields.

Which of the following are appropriate?

  1. Observation. She probably has a viral syndrome.
  2. Head CT scan
  3. Cerebral angiogram
  4. Nerve conduction studies
  5. Liver ultrasound

Reference as: Thomas AR, Uppalapu S. March 2013 critical care case of the month: beware the escargot. Southwest J Pulm Crit Care. 2013;6(3):103-111. PDF

Saturday
Feb022013

February 2013 Critical Care Case of the Month: Thoracentesis Through the Looking Glass

Clement U. Singarajah MD

Jay E. Blum

Allen R. Thomas MD

Henry Luedy MD

Elijah Poulos MD

Tonya Whiting DO

 

Phoenix VA Medical Center

Phoenix, AZ

 

History of Present Illness

A 62 year old man was recently diagnosed with Stage 4 squamous cell left lung cancer with metastases to the pleura, brain and mediastinum. He also had known chronic obstructive pulmonary disease (COPD) with a FEV1 = 1.96 L and a known left side pleural effusion (see Figure 1).

Figure 1. Baseline chest radiograph showing left pleural effusion (red arrow).

He was seen as an outpatient for symptomatic shortness of breath and underwent real time ultrasound guided left sided thoracentesis removing 500 ml of straw-colored fluid. The procedure was uneventful except that near the end, the patient started to cough.  He denied any symptoms post procedure apart from some minor puncture site pain. A routine post procedure chest x-ray was performed (Figure 2).

Figure 2. Post-thoracentesis x-ray (Panel A) and its negative image (Panel B).

What new abnormality is identified on the post-procedure chest x-ray?

  1. Left pneumothorax
  2. Right pneumothorax
  3. Lung “sliding” on the left
  4. New pneumonia in the left upper lobe
  5. Left hilar retraction

Reference as: Singarajah CU, Blum JE, Thomas AR, Luedy H, Poulos E, Whiting T. February 2013 critical care case of the month: thoracentesis through the looking glass. Southwest J Pulm Crit Care. 2013;6(2):63-74. PDF

 

 

Wednesday
Jan022013

January 2013 Critical Care Case of the Month: Different Name, Same Disease...or Is It?

Nathaniel Reyes MD (NReyes@deptofmed.arizona.edu)

Jarrod Mosier MD (JMosier@aemrc.arizona.edu)

 

University of Arizona- AHSC/Pulmonary

1501 N Campbell Ave.

Tucson, AZ 85724-5030

 

History of Present Illness

A 50-year-old female who presented with 2-weeks of worsening cough and shortness of breath.  She presented to another hospital 2-weeks prior to presentation complaining of cough productive of yellow sputum and was diagnosed with bronchitis and discharged home with a normal chest x-ray.  Her symptoms persisted and one day prior to admission she experienced one episode of hemoptysis which prompted her presentation to our emergency department.  She denied fever, chills, night sweats, and complained only of dyspnea on exertion.

PMH/SH

Granulomatous polyangitis (GPA) was diagnosed by renal biopsy in 2004. She subsequent developed end-stage renal disease and has been receiving peritoneal dialysis.  She has never required immunosuppresive therapy. There is no history of tobacco use.  She has lived in Arizona for many years.  She is retired but previously worked as an information technology manager. 

Physical Exam

Vital signs were normal except for an O2 saturation of 91% on room air.  Physical exam was significant only for pale sclerae and bilateral dry crackles.

Laboratory Data

Hemoglobin: 5.4 g/dL; Hematocrit: 17%.  BUN: 43 mg/dL; creatinine: 10.7 mg/dL.   

ABG: PaO2 75; PaCO2 39; pH 7.43 on 2L O2.

P-ANCA: Positive

Myeloperoxidase antibody titer: 83 U/mL

C-ANCA/proteinase 3 antibody titer/Anti-GBM antibodies: negative.

Imaging

Chest X-ray showed diffuse areas of consolidation (Figure 1).

Figure 1. PA Chest X-ray

Which of the following is not appropriate in her management?

  1. Coccidioidomycosis serology

The authors report no conflict of interest.

Reference as: Reyes N, Mosier J. Critical care case of the month: different name, same disease...or is it? Southwest J Pulm Crit Care 2013;6(1):5-11. PDF

 

Saturday
Dec012012

December 2012 Critical Care Case of the Month: Sepsis-like Syndrome in a Returning Traveler

Eric Chase, MD

Eric Ong, MD

John Bloom, MD

 

University of Arizona

Division of Pulmonary and Critical Care Medicine

Tucson, AZ

 

History of Present Illness

The patient is a 56 year old male with a past medical history that is significant only for well controlled hypertension presenting with acute onset of fever, hematuria, jaundice and fatigue. He had been hospitalized in Mexico for the last 5 days. When he failed to improve his friends chartered an airplane and brought him to the U.S. Prior to his hospitalization in Mexico he had traveled to Sierra Leone related to his work as a geologist.

PMH, SH, FH

Past Medical History: Hypertension, gastroesophageal reflux disease

Past Surgical History: Vasectomy

Medications:  Omeprazole, Lisinopril

Social History:  Works as a geologist with recent travel to Sierra Leone, no history of alcohol abuse, intravenous drug abuse, or HIV

Physical Examination

Vital signs: Temperature 97.5° F, Pulse 87 beats/min, Respiratory Rate 18 breaths/min, Blood Pressure 111/84 mm Hg, and SaO2 89% on room air. 

The patient was initially alert, oriented and appropriate.

His pulmonary examination revealed faint bibasilar rales. 

His abdomen was obese, soft, non-tender and non-distended. 

His skin had obvious jaundice and his sclerae were icteric. 

He later decompensated, became altered and developed significant tachypnea.

Admission Laboratory Studies

Significant initial laboratory studies are as follows:  Hemoglobin 11.5 g/dl, Hematocrit 35%, Platelet Count 25,000/uL, Chloride 115 mMol/L, CO2 17 mMol/L, BUN 35mg/dL, Creatinine 1.6 mg/dL, Albumin 1.5 g/dL, Total Bilirubin 13.2 mg/dL, ALT 38 IU/L, AST 97 IU/L, INR 1.7, Fibrinogen 270 mg/dL, D-Dimer 8.37 ug/ml, Venous Lactate 3.9 mMol/L, Urinalysis: Small Blood, 2 RBCs/HPF, Moderate Bilirubin, Urobilinogen 2.0 mg/dL.                    

As part of the workup for possible hemolysis a peripheral blood smear was obtained (Figure 1).

Figure 1. Peripheral smear of the patient’s blood.

Which of the following is the diagnosis?

  1. Malaria
  2. Babesosis
  3. Ehrlichiosis
  4. Relapsing fever
  5. American trypanosomiasis (Chagas disease)

Reference as: Chase E, Ong E, Bloom J. December 2012 critical care case of the month: sepsis-like syndrome in a returning traveler. Southwest J Pulm Crit Care 2012;5:279-85. PDF

 

Thursday
Nov082012

Fatal Dynamic Hyperinflation Secondary to a Blood Clot Acting As a One-Way Valve at the Internal Orifice of a Tracheostomy Tube

Robert A Raschke MD MS

robert.raschke@bannerhealth.com 

 

Professor of Clinical Medicine

Banner Good Samaritan Regional Medical Center

Phoenix, Arizona

 

Abstract

We report the case of a patient who suffered fatal cardiopulmonary effects of a mobile blood clot adherent to the internal orifice of her tracheostomy tube. We believe the clot acted as a one-way valve, leading to dynamic hyperinflation and elevated intrinsic positive end expiratory pressure (iPEEP). This complication of a tracheostomy tube was suggested by clinical findings of expiratory wheezing, hypotension, increasing peak inspiratory pressure, and unusual but distinctive radiographic findings. Confirmation of one-way tracheostomy tube obstruction was difficult, even with a bronchoscopic examination. When this diagnosis is suspected, tracheostomy tube exchange should be rapidly performed.

Case Report 

The patient was a 59-year old woman who had undergone elective colostomy for symptomatic colonic atony. The patient developed a post-operative anastomotic leak, and septic shock. Despite surgical intervention and broad-spectrum antibiotics, acute respiratory distress syndrome ensued, necessitating prolonged mechanical ventilation. On the 29th day of admission, an 8.0 DCT Shiley tracheostomy tube was placed in an open procedure.

On day 33, a chest radiograph demonstrated persistent diffuse pulmonary infiltrates that had not significantly improved over the preceding 3 weeks (Figure 1).

Figure 1.  Portable chest x-ray the morning before the code arrest.

Minor bleeding was noted from the tracheostomy tube. Shortly thereafter, peak inspiratory pressures suddenly rose to the point that adequate tidal volumes could not be delivered by a mechanical ventilator. The inner cannula of the tracheostomy tube was removed. A suction catheter passed easily though the external cannula lumen, and a small amount of blood was suctioned out. However, attempts to bag-ventilate the patient became progressively more difficult. The patient's head and neck became cyanotic and mottled, and a pulse could no longer be detected. Advanced cardiac life support was initiated. Examination was significant for pan-expiratory wheezes throughout the thorax interrupted only by strenuous attempts to at bag-mask inspiration. The trachea was midline, and there was no subcutaneous crepitus. The abdomen was soft.  A bronchoscope passed through the tracheostomy tube easily, revealing a widely patent trachea and major airways. Bag ventilation transiently improved, cyanosis resolved, and a blood pressure of 150/85 was briefly obtained.  Inhaled albuterol and intravenous corticosteroids were administered.  A chest x-ray was performed (Figure 2). 

Figure 2. CXR performed during the code arrest, showing flattening of the diaphragms, and acute narrowing of the cardiac silhouette/vascular pedicle, and acute clearing of pulmonary infiltrates, consistent with hyperinflation.

Bag-ventilation became progressively more difficult, and the patient once more became hypotensive and cyanotic. The bronchoscope again passed easily through the tracheostomy and revealed the same findings as before. Needle thoracostomy was considered to treat possible pneumothorax, but the chest x-ray returned to the bedside demonstrated no evidence of barotrauma. The radiograph demonstrated striking improvement in pulmonary edema, a reduction in the size of the cardiac silhouette and vascular pedicle, and flattening of the diaphragms (see Figure 2 - note: the large radio-opacity overlying the mid-portion of the left lung is the shadow of an adherent transcutaneous pacing pad, not a pneumothorax). Further resuscitative efforts were unsuccessful.

The possibility of tracheostomy dysfunction was re-considered at some length in a postmortem debriefing. We concluded that the most likely explanation for the patient's clinical and radiological findings was dynamic hyperventilation and hemodynamic consequences of severe iPEEP induced by a dysfunction of the tracheostomy tube. 

Autopsy Findings

The tracheostomy tube was left in place, and the pathologist carefully dissected the trachea open from the carina in a caudal direction to expose the internal tip of the tracheostomy tube in-situ. A blood clot was found that nearly completely occluded the internal orifice of the tube (Figure 3, Panel A). The clot swung out of the way of some IV tubing passed inward through the external orifice of the tracheostomy tube, but swung shut again when the IV tube was removed, like a trap door (Figure 3, Panel B).

Figure 3.  Longitudinal view of the open tracheal lumen at autopsy.  Orientation: the left side of the figure is rostral. In panel A, the distal orifice of the tracheostomy tube can be seen to be nearly completely obstructed by a thrombus (black arrow). In panel B, the thrombus (black arrow) can be seen to be pushed aside by the passage of a plastic catheter (white arrow),

This clot appeared to function as a one-way valve, allowing inward passage of air, suction catheters, and a bronchoscope, but severely obstructing exhalation. We reasoned that such an obstruction could lead to wheezing and dynamic hyperinflation, and could explain the clinical and radiographic findings. Ultimately, severe iPEEP compromised cardiac preload, leading to pulselessness and death. 

No other cause for the patient's clinical syndrome was found - specifically, the patient had no antecedent history of asthma, had received no new medications on the day of the arrest, nor had any dermatological findings suggestive of anaphylaxis. The autopsy failed to reveal pulmonary embolism, mucous plugging, pneumothorax, or any histological evidence of asthma. 

Discussion

We are not the first to report dynamic hyperinflation as a complication of uni-directional tracheostomy tube obstruction (1). Several experienced clinicians at our institution recall dealing with this entity before, therefore, we suspect that it is not as rare as the paucity of clinical reports suggests. We felt that the clinical, radiological and postmortem findings in our case are sufficiently interesting, and the danger of missing this diagnosis sufficiently great, to warrant a brief review. 

Other types of tracheostomy tube dysfunction can cause high airway pressure and hypotension. Bi-directional tube obstruction from blood, dried secretions, or balloon hyperinflation is the most common (2,3). Barotrauma related to tracheostomy tubes may occur when they become displaced into the soft tissues of the neck, or into the pleural space, or when the cutaneous tracheostomy wound is sutured in an overly constrictive manner (4). 

We learned three important lessons from this unfortunate case:

  1. Clinical and radiographic findings can suggest the diagnosis of expiratory tracheostomy obstruction in a patient ventilated through a tracheostomy tube. The key clinical findings are: expiratory wheezing, hypotension, increasing iPEEP, and increasing peak inspiratory pressure.  Unexpected radiographic improvement in pulmonary edema may suggest the presence of occult iPEEP if it is not directly measured. 
  2. The diagnosis of unidirectional obstruction of a tracheostomy tube can be difficult to confirm.  The easy passage of suction catheters, or a bronchoscope, does not rule it out.  If bronchoscopy is performed emergently, the internal lumen and internal orifice of the tracheostomy tube should be examined with extreme deliberation.  This can be difficult during cardiopulmonary resuscitation.  If visualized, the potential detriment of small mobile clots should not be under-estimated.
  3. Alternative airway access should be immediately pursued in patients with tracheostomy tubes who are difficult to ventilate.  In dire clinical situations, the best diagnostic test might be to simply see if the patient improves with a new airway.  If the tracheostomy tract is likely to be mature (> 5 days old), the tracheostomy tube can simply be exchanged.  If the tract is immature, or if tube displacement is suspected, oral laryngoscopic intubation should be performed immediately.  The tracheostomy tube may need to be pulled out in order to accommodate the endotracheal tube in the trachea.  Either of these actions would likely have saved our patient's life.

References

  1. Timmus HH.  Tracheostomy: An Overview of implications, management, and morbidity.  Advances in Surgery 1973;7:199-233.
  2. Saini S, Taxak S, Singh MR.  Tracheostomy tube obstruction caused by an overinflated cuff.  Otolaryngol Head Neck Surg 2000;122:768-9.
  3. Rowe BH, Rampton J, Bota GW.  Life-threatening luminal obstruction due to mucous plugging in chronic tracheostomies: three case reports and a review of the literature.  J Emerg Med 1996;14:565-7.
  4. Tayal VS. Tracheostomies. Emerg Med Clin North Am 1994;12:707-27.

The author reports no financial support and no conflict of interest for this publication.

Reference as: Raschke RA. Fatal dynamic hyperinflation secondary to a blood clot acting as a one-way valve at the internal orifice of a tracheostomy tube. Southwest J Pulm Crit Care 2012;5:256-61. PDF