Pneumomediastinum diagnosed from a remote tele-ICU center?


Background: The propagation of remote “telemedicine” has allowed intensivists (and other medical professions) to expand their ability to provide critical care medicine services to intensive care units (ICUs). The physical exam is a pertinent skill that all providers learn early in their medical careers. Key components of the physical exam can help a clinician narrow the differential diagnosis. Even with modern monitoring devices and high-powered imaging, it is hard to replicate the physical exam on a critical care patient from a tele-medicine center.

Case presentation: An experienced intensivist working in a telemedicine (Tele-ICU) center reviewed the daily chest radiograph on a patient with a complex prolonged ICU course. The radiograph was immediately recognized as being concerning for an acute case of pneumomediastinum in a patient with recent tracheostomy manipulation. However, the intensivist was unable to corroborate his suspicions with a good physical exam as the differential diagnosis list was explored.

Conclusions: Acute pneumomediastinum is a severe disease process arising from numerous etiologies that can be life threatening. This disease process can often times be diagnosed from plain chest radiography alone. However remote telemedicine patient care should never supersede a direct bedside physical exam. Every good clinician knows that the fundamental physical exam truly is fundamental.

Authors: Keith Azevedo, Brian T. Wessman

Critical care medicine ocular emergency presentation: Can you see it?


Introduction: Ocular emergencies are not a common presentation in the intensive care unit. Intensivists should have a broad differential for the “red eye” and involve ophthalmology appropriately for ocular emergencies.

Background: Ocular emergencies can lead to permanent vision loss if not identified in a timely fashion.

Case description: A patient with hyponatremia and bacteremia admitted to the intensive care unit (ICU) developed an acute painful red eye. Physical exam findings and images are shared.

Conclusion: Due to an acute ocular emergency, this critically-ill patient required transfer to a higher level of care and subspecialty management.

Clinical significance: Education about ocular emergencies is provided for the intensivist; including diagnosis, management, and complications.

Authors: Stephanie Charshafian, Brian T. Wessman

Pneumoperitoneum following cardiopulmonary resuscitation in a COVID19 patient

Case presentation

An 86-year-old Hispanic lady was brought to the emergency department in acute respiratory distress. She had tested COVID-19 positive a week prior to her presentation. She had a past medical history of chronic hypertension, gastric ulcer, abdominal hernia, anxiety, and arthritis. On arrival blood pressure was 130/72 mmHg, heart rate 85/min, respiratory rate 33/min, temperature 98.8 ºF, with oxygen saturation of 82% while breathing room air. Further testing revealed ground glass opacities and interstitial infiltrates in both lungs on computed tomography. Over the next few hours, the patient deteriorated with her oxygen saturation dropping 40% followed by asystole. Cardiopulmonary resuscitation (CPR) was immediately started. She was intubated on first attempt. CPR continued for 15 minutes and multiple doses of epinephrine were given. Return of spontaneous circulation was obtained with sinus rhythm that required vasopressors to maintain reasonable mean arterial pressures. A post resuscitation chest radiograph depicted sub diaphragmatic free air suggesting spontaneous pneumoperitoneum (Figure 1). All prior imaging tests failed to reveal this new finding. Her abdomen was mildly distended but no signs of tension pneumoperitoneum or inferior vena cava compression were found on physical or ultrasonographical exam. A surgical consultation was obtained. In view of her dismal prognosis, after discussing with her family, limitation of care followed.

Authors: Gabriel Cervera, Daryelle S. Varon, Joseph Varon

Giant extrathoracic hematoma in a COVID-19 patient

Case presentation

A 69-year-old lady presented to our emergency department with a two week history of shortness of breath, fever, and dry cough. Chest computed tomography revealed patchy ground glass opacities throughout both lungs, most pronounced in the mid-to-lower lung zones bilaterally, with peripheral distribution. She was admitted to the hospital with the presumptive diagnosis of coronavirus disease 2019 (COVID-19) pneumonia. She received our standard MATH+ protocol (hydroxychloroquine, intravenous ascorbic acid, zinc, thiamine, melatonin, azithromycin, vitamin D3, and enoxaparin). This was followed by oral anticoagulation with warfarin. On day 18, she complained of severe right breast pain. Upon examination she...

Authors: Elizabeth Gamboa, Joseph C Gathe Jr, Joseph Varon

Acute necrotizing encephalopathy secondary to COVID-19

A 54-year-old gentleman without significant past medical history presented to our emergency department with complaints of shortness of breath and fever. On arrival he was very disoriented, and unable to communicate well. He was found to be positive for SARS-CoV-2 and had severe pneumonia. On hospital day 8, he abruptly began to decline, initially presenting with elevation in blood pressure, and soon thereafter with severely decreased level of consciousness. This was followed by a cardiac arrest, that was treated, and he had eventual return of spontaneous circulation within 15 minutes. Despite this, the patient never regained consciousness. A head computed...

Authors: Swethen Dushianthan, Elizabeth Gamboa, Joseph Varon

Under pressure… Pressure pushing down on me

A 70-year-old male without significant medical history, presented to the hospital after having been trapped under a piece of industrial equipment for several hours. In addition to multiple orthopedic fractures and compartment syndrome requiring left upper extremity fasciotomies, he was found to have rhabdomyolysis and renal failure. The patient was aggressively resuscitated with crystalloid fluids. He arrived to the Surgical Intensive Care Unit (SICU) intubated and was ultimately started on continuous veno-venous hemodialysis (CVVHD) for metabolic derangements including hyperkalemia. Tube feeds were started on hospital day 1 and the patient was noted to have been having good bowel function.

Authors: Avi Ruderman, Brian T. Wessman

Internal jugular vein thrombosis and central venous catheter

A sixty-seven-year-old gentleman, with atherosclerotic cardiovascular disease, stable angina, and hypertension was admitted to the hospital with several episodes of chest pain. An electrocardiogram revealed ST-T changes in the anterior wall. A coronary angiography followed by an angioplasty resulted in placement of 2 stents for critical lesions on the left anterior descendent artery. Within minutes, the patient became hypotensive with signs of hypoperfusion. Bedside echocardiography revealed cardiac tamponade. An emergency pericardial drainage was placed, and the patient taken to the cardiac catheterization laboratory where a repeat angiogram revealed a right coronary artery perforation as well as a small distal branch of the posterior descendent artery.

Authors: Ricardo de Jesús Avendaño-Garnica, Santiago Herrero, Joseph Varon

Sigmoid volvulus: An image telling the story

A 77-year-old gentleman, with past medical history of dementia and psychosis, presented to the emergency department with a chief complaint of abdominal distention. X-ray imaging of the abdomen revealed air filled distended loops of large bowel (Figures 1A and 1B). Computerized tomography (CT) revealed marked dilatation of the large intestine, from the cecum to the sigmoid colon where there is a beak-shaped transition as well as multiple air fluid levels without free air (Figures 2a and 2b). A bedside colonoscopic decompression was performed with resolution of the volvulus.

Authors: Gerardo Rivera, Salim Surani, Joseph Varon

Unusual presentation of tension pneumoperitoneum during endoscopic submucosal dissection of early gastric tumor

Tension pneumoperitoneum is a well-known but rare complication of upper gastrointestinal endoscopy. It is defined as the massive accumulation of air in the peritoneal cavity, which results in a sudden increase in intraabdominal pressure resulting in hemodynamic or ventilatory compromise. The presentation varies from intense abdominal pain and tenderness to imminent collapse.

Authors: Phui Sze Au Yong, Gek Kim Sharon Ong

Cardiac tamponade in acute necrotising pancreatitis


Objective: This case report highlights cardiac tamponade as a potentially significant complication of severe acute pancreatitis.

Settings: This patient was admitted to the Ng Teng Fong general hospital emergency department. He was subsequently admitted to the Intensive Care Unit (ICU) in the same hospital.

Patients: A 58-year-old male presented with severe acute gallstone pancreatitis with a Glasgow-Imrie criteria of 3. He was admitted for haemodynamic instability and acute respiratory distress syndrome (ARDS). The patient developed new-onset atrial fibrillation, persistent hypotension despite fluid resuscitation and increasing dependence on high inotropic support.

Investigations: A CT abdomen incidentally discovered an accumulation of pericardial fluid. Bedside echocardiography confirmed the presence of a large pericardial effusion consistent with cardiac tamponade. A CT scan revealed severe necrotising pancreatitis with a significant peripancreatic fluid collection.

Interventions: An emergency pericardiocentesis was performed and a pericardial drain was inserted. Eight hundreds ml of haemoserous pericardial fluid was drained over a period of 2 days. The patient’s haemodynamic status improved significantly after drainage of pericardial fluid.

Conclusion: Cardiac tamponade is one of the rare but clinically significant complications of severe acute pancreatitis and should be treated with a high index of suspicion in cases of acute pancreatitis with hypotension.

Authors: Christopher Thong, Jolene Loi, Bryan Chong, Lu Hern Goh

The case of the malpositioned feeding tube… while in plain sight

Patient WS is a 63-year-old male who presented to the Emergency Department (ED) with a chief complaint of progressive shortness of breath (SOB) over the past two weeks. Associated symptoms at time of presentation included acute bilateral lower extremity edema, orthopnea, and paroxysmal nocturnal dyspnea. His past medical history was significant for diabetes mellitus type II, hypertension, hypothyroidism, paroxysmal atrial fibrillation, paroxysmal ventricular fibrillation, non-ischemic cardiomyopathy (ejection fraction of 25%), severe mitral valve regurgitation, and newly diagnosed adenocarcinoma of the colon. The patient’s surgical history was significant for bi-ventricular ICD placement and gastric sleeve surgery.

Authors: Thomas Lynch V, Brian T. Wessman

Ureteral stents, sepsis and acute kidney injury: Iatrogenic imperfecta!

Case presentation

A 62-year-old woman with a past history of placement of bilateral ureteral “JJ” stents, presented to the hospital complaining of fever, chills, abdominal pain, oliguria and was found to be hypotensive. She was admitted to the intensive care unit (ICU), with the diagnosis of sepsis secondary to a urinary source. Her white blood cell count (WBC) was 21,200/mm3, blood urea nitrogen (BUN) 40 mg/dL, and serum creatinine 2.1 mg/dL. Her systolic blood pressure was 75 mmHg after administration of bolus of intravenous fluid (30 ml/Kg). She was then started on norepinephrine with improvement in her mean arterial blood pressure.


Mediastinal lipoma with vascular compression

Case description

A 56-year-old gentleman presented to the emergency department with shortness of breath and neck swelling of a couple of weeks duration. After a comprehensive physical examination and chest radiograph revealing an upper mediastinal abnormality, a computed tomography (CT) scan of the chest (Figures 1A and 1B) depicted a 8x7x5.7 cm mass with homogenous fat density and smooth margin, that was causing compression and anterior displacement of the superior vena cava and the left brachiocephalic vein. The patient underwent urgent surgery with removal of the tumor and postoperatively his symptoms had subsided.


Peripherally-inserted central catheters: Watch for retained wires!

An increasing number of patients are being admitted to critical care units with multiple chronic medical conditions. In some of these patients, intravenous access is a challenge. With a concern for indwelling catheter infections, peripherally inserted central catheters (PICC). These lines have been advocated due to their lower rate of complications and comfort to the patients. PICC are routinely inserted by physicians and trained nurses. Complications such as pneumothorax and infections are lower than in central venous lines and the incidence of retained guide wire is minimal and in some cases unrecognized.
We recently had one such case. An elderly man with sepsis required a PICC placement. A trained nurse attempted to place it when she recognized that the guidewire was missing, as the vessel dilator was being used. A chest radiograph confirmed that the guidewire remained in the patient’s chest cavity. Interventional radiology successfully retrieved the missing wire. Vigilance and frequent refresher courses are required to evaluate the competency among health care workers placing these catheters to help avoid complications.


Severe abdominal pain in a Jehovah’s Witness patient

A 76-year-old lady, with past medical history of hypertension, presented to the hospital with complains of severe right upper abdominal pain for 6 days prior to admission. A complete laboratory evaluation was non-revealing. An emergency computed tomography (CT) scan of the abdomen and pelvis revealed a hepatic artery aneurysm measuring 4 x 4 x 6 cm with unstable appearance (Figures 1,2,3). As the patient was a Jehovah’s Witness, and was not going to consent to receive any blood or blood product transfusion if needed, she was taken to the angiography suite emergently where a hepatic artery angiogram was performed. This was followed by embolization with an 8 mm coil, with successful reduction in the size of the aneurysm.

Severe abdominal pain in a Jehovah’s Witness patient