SLIDE PRESENTATION/QUIZ

Israr Bashir

CASE 1A 50 YEAR-OLD MAN,INTUBATED AFTER HE PRESENTED IN STATUS EPILEPTICUS.POST-INTUBATION CXR SHOWN.FINDINGS IN CXR ??

WHAT ABNORMAL FINDINGS CAN YOU SEE ON HIS CXR?

Tip of the ET tube being less than 2cm from the carina

Important abnormality is an injury affecting the right glenohumeral joint and proximal humerus.

MANAGEMENT ??

This man’s dislocation was reduced while he was intubated and sedated

Subsequent operative repair.

CASE 2

Broken-hearted chest drain!!!

86 YEAR-OLD MALE PRESENTED WITH SOB. HE DEVELOPED A COMPLICATION AFTER INSERTION OF A LEFT CHEST DRAIN.

THE CT BELOW DEMONSTRATES THIS COMPLICATION…

WHAT IS THE COMPLICATION?

The chest drain is in the left ventricle.

MANAGEMENT…???

Identified by the presence of pulsatile bright red blood coming from the drain.

Clamping the drain ! Not taking the drain out. Cardiac surgery to remove the drain and

repair the heart.  Appropriate reporting and follow-up.

CASE 3

Sudden onset blue leg!!!

56 YEAR OLD WOMAN WITH SEVERE PNEUMONIA IN THE ICU.HER LEG HAS SUDDENLY TURNED BLUE:

WHAT IS THE DIAGNOSIS?

Phlegmasia Cerulea Dolens (Painful blue edema)

Manifestations of venous thrombosis . Result from acute massive venous thrombosis and

obstruction of the venous drainage of an extremity. 

MANAGEMENT…???

Traditional treatment - Anticoagulation Invasive therapies Thrombolysis, Thrombectomy

CASE 4

Seizures, Somnolence and a Scary ECG!!!

18-YEAR OLD MALE IS BROUGHT BY EMS FOLLOWING A GENERALISED SEIZURE AT HOME. ON ARRIVAL HE IS COMATOSE WITH A GCS OF 3 AND POOR RESPIRATORY EFFORT. PUPILS ARE SYMMETRICALLY DILATED. BLOOD SUGAR IS NORMAL. BP IS 70/40. HIS ECG IS SHOWN BELOW:

DESCRIBE THE ECG FINDINGS…???

Regular broad complex tachycardia Rate 130 bpm Right axis deviation Very broad QRS complexes (160ms) Terminal R wave in aVR > 3mm; RBBB Markedly prolonged QTc 590 ms Non-specific T wave abnormalities with T-

wave inversions in V1-2 & lead III

WHAT IS THE LIKELY DIAGNOSIS…???

TCA Poisoning.

The degree of QRS broadening on the ECG is correlated with adverse events:

QRS > 100 ms is predictive of seizures

QRS > 160 ms is predictive of ventricular arrhythmias

MANAGEMENT…??? IV, O2 and Monitor. IV sodium bicarbonate 100 mEq (1-2 mEq / kg); repeat every few

minutes until BP improves and QRS complexes begin to narrow. Intubate. Hyperventilate to maintain a pH of 7.50 – 7.55. Activated charcoal. Crystalloid bolus (10-20 mL/kg). Consider vasopressors If arrhythmias occur, the first step is to give more sodium

bicarbonate. Lidocaine (1.5mg/kg) IV is a second line agent once pH is > 7.5. Treat further seizures with IV benzodiazepines.

CASE 5

A Subtle Sign of Something Sinister…

65-YEAR M,90 MINS OF CENTRAL CHEST PRESSURE AWOKE HIM FROM SLEEP. HE THINKS HE HAS ‘INDIGESTION’. NON-RADIATING, WITH MILD SOB, NO NAUSEA, VOMITING OR DIAPHORESIS. EX-SMOKER .THERE IS NO PREVIOUS MEDICAL HISTORY. PULSE= 54 BPM, BP-127/86 AND O2 SAT 98% ON RA. PAIN IMPROVED SLIGHTLY WITH SL NITRATES, ALTHOUGH HE STILL HAS SOME ONGOING CHEST DISCOMFORT. 

DESCRIBE THE ECG…???

Sinus rhythm at 54 bpm Normal axis Normal intervals Borderline left atrial enlargement with a bifid

P wave in lead II Normal ST segments and T waves, except for

some non-specific T-wave flattening in aVL

INVERTED U WAVES IN THE LATERAL LEADS I, V5 AND V6 (AND POSSIBLY ALSO IN LEADS II AND III)

SIGNIFICANCE OF THESE ECG FINDINGS…???

Very specific sign of myocardial ischaemia Earliest marker of unstable angina and

evolving MI May be observed during attacks of

Prinzmetal angina Left ventricular dysfunction With this patient’s history, the U wave

inversion would be strongly suggestive of an acute coronary syndrome (unstable angina or NSTEMI).

HOW WOULD YOU MANAGE THIS PATIENT…???

Manage as an ACS Serial ECGs and troponins. No indications for thrombolysis or emergent

PCI Admitted - Angiography

CASE 6

Palpable Excitement!!!

A 76 YEAR-OLD MAN PRESENTS WITH SPREADING VIOLACEOUS RASH OVER MOST OF HIS BODY. HE NOTICED IT ON HIS FEET WHEN HE WOKE UP. HIS OBSERVATIONS ARE UNREMARKABLE.NO FEVER, AND THE RASH IS SLIGHTLY ITCHY.THE DAY PREVIOUSLY HE HAD RECEIVED CHEMO FOR DUKE’S B STAGE BOWEL CANCER. NOT TAKING ANY OTHER MEDICATION. HE HAS HAD A DRY COUGH WHICH HE HAS NOT TOLD HIS ONCOLOGIST ABOUT.

THESE ARE THE LESIONS ON HIS LEGS AND RIGHT HAND:

WHAT IS THIS SKIN MANIFESTATION..???

Palpable purpura

WHAT UNDERLYING PATHOLOGICAL PROCESS DOES THIS IMPLY…???

leukocytoclastic vasculitis — 

histopathologic term used to denote small-vessel vasculitis.

WHAT IS THE MOST IMPORTANT CAUSE TO EXCLUDE AND/OR TREAT IN THE EMERGENCY SETTING..???

Sepsis — especially meningococcemia

CASE 7

Bump and blur!!!

71 YEAR-OLD MAN TRIPPED AT HOME AND BUMPED HIS FOREHEAD ON THE WALL. NO LOC. SUSTAINED A MINOR BRUISE ON HIS FOREHEAD .HIS ONLY COMPLAINT IS MARKEDLY BLURRED VISION IN HIS RT EYE..HAD PREVIOUS CATARACT SURGERY ON BOTH EYES.

WHAT IS THE DIAGNOSIS…???

Anterior dislocation of an intraocular lens

MANAGEMENT OF THIS CONDITION…???

Immediate ophthalmology consultation Rx options vary from observation to surgical

removal  and replacement.

CASE 8

A Fiendish Finding!!!

21 YEAR-OLD F, PRESENTS WITH ACUTE ONSET ABDOMINAL PAIN AND VOMITING FOUR YEARS AFTER A MAJOR MOTOR VEHICLE ACCIDENT.  A CHEST X-RAY IS PERFORMED:

WHAT IS THE LIKELY DIAGNOSIS…???

Traumatic rupture of the diaphragm with strangulation of viscera in the chest.

Ambroise Paré, in 1579, described the first case of diaphragmatic rupture diagnosed at autopsy.

CHEST X-RAY FINDINGS INCLUDE:

Presence of bowel or stomach gas in the chest

NG tube that passes through or finishes in the chest

Irregularity of the diaphragma An elevated hemidiaphragm Mediastinal shift without pulmonary or

intrapleural cause

HOW COULD THIS COMPLICATION HAVE BEEN PREVENTED…???

A high index of suspicion is required.

TREATMENT…???

Surgical repair of the diaphragm. In this case, resection of strangulated viscera

may be required.

CASE 9AN OTHERWISE HEALTHY 45-YEAR-OLD WOMAN PRESENTED WITH A 6-MONTH HISTORY OF GRADUAL VISUAL LOSS IN BOTH EYES.

Corneal snowflakes

WHAT IS THE DIAGNOSIS…?

igG-kappa monoclonal gammopathy

CASE 10

Another complication of facial trauma!!!

A 27 YEAR OLD M, WITH HEAD AND EXTENSIVE FACIAL TRAUMA IS ADMITTED TO THE ICU AFTER A NEUROSURGICAL INTERVENTION FOR AN ACUTE SUBDURAL HAEMORRHAGE.THERE HAS BEEN DIFFICULTY WITH OXYGENATION IN THE OR. CXR 1 was performed at the time of admission to ICU

CXR 2 WAS PERFORMED AFTER A THERAPEUTIC INTERVENTION.

DESCRIBE CHEST X-RAY 1…

ETT in appropriate position Orogastric tube in an appropriate position. Right upper lobe collapse. Left lung is significantly hyperinflated due to the

provision of a large amount of PEEP.

WHAT IS THE DIAGNOSIS…???

Right upper lobe collapse

history provided likely to be due to a blood clot in the right upper lobe bronchus.

WHAT THERAPEUTIC INTERVENTION NEEDS TO BE PERFORMED..???

Bronchoscopy

CASE 11

A 25 year old man presents with a four day history of increasing left eye pain, photophobia and decreased vision.

DESCRIBE AND INTERPRET HIS PHOTOGRAPH…

•Conjunctival injection

•Opacified cornea and

•Discharge.

•Hypopyon

DIAGNOSIS…???

• Consider anterior eye inflammatory process

(keratitis, uveitis).

CASE 12

5 year-old male with developmental delay presents with non-bloody and non-bilious vomiting over 10 days; bowel movements are normal. Four weeks ago he was placed in a hip-spica cast following a motor vehicle crash.

ABDOMINAL X-RAY IS BELOW.

DIAGNOSIS…???

CAST syndrome

Also known as Superior Mesenteric Artery Syndrome

Caused by extrinsic compression of the SMA with ensuing partial gastric outlet obstruction

Commonly seen in the second decade of life when there is increased spinal flexibility and truncal casting increases lumbar lordosis.

TREATMENT …???

IV replacement therapy NG tube to decompress the stomach and

duodenum and Replacement of the cast.

WHATS WRONG WITH THIS XRAY???

Case 13

DIAGNOSIS…???

Boxer's (or Brawler's) Fracture Fifth metacarpal neck fracture.

MANAGEMENT…???

Non-displaced fractures:

RICE therapy, gutter splint, and Ortho follow-up. Displaced, rotated, or angulated fractures (>40 degrees):

Closed reduction may be attempted

Surgical fixation usually required.

CASE 14WHAT MIGHT THIS FINDING BE A CONSEQUENCE OF…???

Elevated methaemoglobin levels Intra-abdominal haemorrhage Congenital melanocyte proliferation Immunosuppression with concurrent

human herpes virus 8 infection

GREY TURNER'S SIGN

Suggesting retroperitoneal haemorrhage

CASE 15

Something’s not right!!!

26 YEAR-OLD MAN PRESENTED TO THE ED WITH CHEST PAIN. TRIPPED ON SOME STEPS AND THE RIGHT-SIDE OF HIS CHEST COLLIDED WITH THE HANDRAIL.

WHAT ARE THE CHEST RADIOGRAPH FINDINGS…???

There is a right-sided aortic arch. The trachea is deviated to the left rather

than the right. There is no evidence of traumatic injury or

situs inversus. About 1 in 100,000 people have a right-sided

aorta. Right-sided aortic arch can simply be mirror

image of a normal left-sided arch.

QUESTIONS…???

THANK YOU