Medical Image of the Week: Stomach Rupture

Figure 1. Cross table view of patient showing massively dilated abdomen.

Figure 2. Chest x-ray showing air under diaphragm (arrow).

A 61-year-old man was transferred from another hospital for further care. He had a history of oxygen-dependent chronic obstructive pulmonary disease in addition to congestive heart failure, hypertension and diabetes mellitus. He had been seen earlier in the day at his primary care physician’s office for a routine visit. Although he was asymptomatic, emergency medical services (EMS) were called because of significant hypoxemia detected by pulse oximetry. EMS noted that the patient said he “feels OK”. However, a decision was made to intubate the patient. Multiple failed intubation attempts failed and he suffered a cardiopulmonary arrest. He was successfully resuscitated and underwent a cricotracheotomy with an uncuffed endotracheal tube. When transferred his mouth was taped shut and his nose clamped. His abdomen was markedly distended and tympanic (Figure 1). A supine chest x-ray showed air under the diaphragm. Abdominal exploration showed a ruptured stomach which was repaired. He made an uneventful recovery.

The difficult airway outside the operating room can be problematic. While preparation for airway control are made, preoxygenation should be performed (1). The patient should be placed in the “sniffing” position and mask ventilation performed. Appropriate positioning - with the tragus of the ear elevated parallel to the sternum - may require special preparation in obese patients. When adequate preoxygenation is accomplished endotracheal intubation can be attempted. However, when endotracheal intubation fails and/or mask ventilation is inadequate a variety of advanced intubation techniques can be considered including a laryngeal mask airway, fiberoptic intubation, cricothyroidotomy, or transtracheal jet ventilation (1).

Confirmation of proper endotracheal tube placement should be completed in all patients (2). Physical examination methods such as auscultation of chest and epigastrium, visualization of thoracic movement, and fogging in the tube are not sufficiently reliable to confirm endotracheal tube placement. During intubation, direct visualization of the endotracheal tube passing through the vocal cords into the trachea, especially with the use of a videolaryngoscope, constitutes firm evidence of correct tube placement. Use of an end-tidal carbon dioxide detector (i.e., continuous waveform capnography, colorimetric and non-waveform capnography) to evaluate and confirm endotracheal tube position should be performed.  For patients in cardiac arrest and for those with markedly decreased perfusion other methods of confirmation such as an esophageal detector device, ultrasound, or bronchoscopy should be used.

Robert A. Raschke, MD

University of Arizona College of Medicine Phoenix

Phoenix, AZ USA

References

1. Langeron O, Amour J, Vivien B, Aubrun F. Clinical review: management of difficult airways. Crit Care. 2006;10(6):243. [CrossRef] [PubMed]
2. American College of Emergency Physicians. Verification of endotracheal tube placement. January 2016. Available at: https://www.acep.org/Clinical---Practice-Management/Verification-of-Endotracheal-Tube-Placement/#sm.00004sk8v7vduedxxs618zbgnij0n (accessed 1/24/18).

Cite as: Raschke RA. Medical image of the week: stomach rupture. Southwest J Pulm Crit Care. 2018;16(1):53-4. doi: https://doi.org/10.13175/swjpcc008-18 PDF 

Medical Image of the Week: Methemoglobinemia

Figure 1. A: cyanotic lips and tongue. B: restoration of reddish color after methylene blue infusion.

Figure 2. Patient’s blood showing a chocolate brown color.

A 62-year-old man with a sternal infection post-coronary artery bypass grafting was transferred because of increasing oxygen requirements, decreased mental status and Candida paralopsis fungemia. He had been treated with multiple antibiotics including sulfonamides and had eventually undergone a tracheostomy. Cetacaine was used for complaints of a sore throat. Physical examination showed cyanotic lips and tongue (Figure 1A). Blood drawn was a chocolate brown color (Figure 2). His SpO2 was 88%, however, arterial blood gases showed his SaO2 was 100% and his PaO2 453 mmHg. Co-oximetry showed 26% methemoglobin. He was administered 0.2mL/kg of 1% solution of methylene blue and his cyanosis rapidly cleared (Figure 1B).

Methemoglobinemia is a condition characterized by increased quantities of hemoglobin with iron oxidized to the ferric (Fe3+) form (1). Methemoglobin is useless as an oxygen carrier and thus causes a varying degree of cyanosis and hypoxia. It can be genetic but is usually caused by exposure to drugs or toxins. Symptoms are proportional to the fraction of methemoglobin. A normal methemoglobin fraction is about 1%. Symptoms associated with higher levels of methemoglobin are: 3-15% - cyanosis; 25-50% - headache, dyspnea; 50-70% - cardiac arrhythmias, altered mental status, delirium, seizures, coma; >70% - death. Drugs most commonly associated with methemoglobinemia include topical and injected local anesthetics (benzocaine, lidocaine, cetacaine), sulfonamides (dapsone), and nitrates (nitroprusside).

Intravenous methylene blue, a reducing agent, is the traditional antidotal agent (1). Exchange transfusion and hyperbaric oxygen treatment are second-line options for patients with severe methemoglobinemia who do not respond to methylene blue or who cannot be treated with methylene blue (e.g., those with glucose-6-phosphate dehydrogenase [G6PD] deficiency).

Robert A. Raschke, MD, MS

University of Arizona College of Medicine-Phoenix and Banner University Medical Center

Phoenix, AZ USA

Reference

1. Denshaw-Burke M. Methemoglobinemia. Medscape. Nov 14, 2017. Available at: https://emedicine.medscape.com/article/204178-overview (accessed 1/11/18).

Cite as: Raschke RA. Medical image of the week: methemoglobinemia. Southwest J Pulm Crit Care. 2018;16(1):49-50. doi: https://doi.org/10.13175/swjpcc007-18 PDF