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Internal Medicine

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A central line placed by CRNA!

Can you identify the complication?

Harsh Sura
Ibrahim Makki Al Abdullah

RT INTERNAL CAROTID

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What do you want to do next?

Harsh Sura
Israr Khan
Nader Guma

Thank you, in addition to the pneumomediastinum and SQ emphysema, there is also a pneumothorax on the right side and a chest tube is needed since this patient is on the ventilator. @Everyone

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What do you think is causing this abnormality indicated by the yellow circle?

@Everyone

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A 78-year-old man with known COPD (Global Initiative for Chronic Obstructive Lung Disease grade III, group D) is admitted with worsening dyspnoea and increased sputum volume and purulence for the past 3 days. He is fully conscious and not confused or agitated. His temperature is 37.8°C, SpO2 is 96%, he is tachycardic (110 beats per min) but normotensive, tachypnoeic with a respiratory

rate of 30 breaths per min, and there is widespread wheeze on auscultation. A chest radiograph shows hyperinflated lung fields but no new consolidation. Laboratory examination results include C-reactive protein 45 mg·L−1 and neutrophils 12×109 cells per L. Arterial blood gases on arrival are as follows: pH 7.28, PaCO2 76 mmHg, PaO2 122 mmHg and bicarbonate concentration 33 mmol·L−1


What is the most appropriate form of management?

  • 0%Endotracheal intubation and mechanical ventilation

  • 0%NIV

  • 0%High-flow nasal cannula oxygen therapy

  • 0%Optimal medical treatment and close monitoring


Desmond Boakye Tanoh
Israr Khan

@Everyone The arterial blood gases show acute hypercapnic respiratory acidaemia due to decompensated chronic type 2 respiratory failure. The high PaO2 suggests recent administration of oxygen with an unrestricted inspiratory oxygen fraction (FIO2), most probably by the emergency services prior to his arrival at hospital.


High levels of inspired oxygen can lead to hypercapnia due principally to ventilation–perfusion mismatching and loss of hypoxic pulmonary vasoconstriction. In this situation, initial management should be optimal medical therapy including controlled oxygen therapy to achieve a target saturation of 88–92%, bronchodilators and systemic corticosteroids. NIV should be started when pH <7.35 and PaCO2 >49 mmHg persist despite these measures and this should be assessed by repeat arterial blood gas estimation, typically after an interval of approximately 1 h.

Modificato
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Take a look on this mode of ventilation and give your answers to the following:

  1. What is this mode?

  2. How do breaths start in this mode?

  3. What does the machine do when the breath is started?

  4. How does inspiration end in these breaths?

@Everyone any one would like to contribute on this mode. I am posting the basic modes that any resident should be familiar with and you will have board questions on them!

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Nader Guma
Tarek Slibi
Ayesha Khan
Seif Hayek

47 year old male with no significant PMHx who presented to ED c/o chest pain and sob x 12h

As a part of ED work up they ordered stat TTE I did his echo and as everyone can see a large mobile echogenic mass (measuring ~ 5-6 x 2 cm) moving in-and-out of the tricuspid annulus, most likely representing thrombus/emboli in transit.

Final diagnosis was

PE in patient with RCC

occur due to tumors emboli from the involvement of the IVC with local tumor extension



Hossam Aziz
asimdayala
Manar  Ismail
Seif Hayek

Great case, thank you Nader.

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This is a 26 yo M with history of obesity and asthma, who is presenting with shortness of breath x3 days, tested positive for influenza A, started on bilevel oxygenation for respiratory distress. Patient was noted to feel more short of breath and complain of neck swelling. CT as above.


What is your diagnoses(s)?

How would you manage this patient with these new findings?


Mazen Kherallah
Nader Guma
Seif Hayek
Sadia Usmani

@Everyone

A nice narrative review of Pneumomediastinum and pneumothorax in ARDS

https://med.amegroups.org/article/view/8318/html

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The following is a screenshot of a mechanical ventilation mode. The top graph represents pressure over time. The middle graph is the flow over the time and the bottom graph is the volume over time.

Please examine this graphs carefully, and let's answer the following question:

What is this mode of mechanical ventilation?

  • 0%Pressure support ventilation (PSV)

  • 0%Assist/control mode of ventilation (A/C)

  • 0%Synchronized Intermittent Mandatory Ventilation (SIMV)

Now examine the third delivered breath and answer the following questions:


Thank you for your answers

This is assist control mode of ventilation. AC ventilation is a volume-cycled mode of ventilation. It works by setting a fixed tidal volume (VT) that the ventilator will deliver at set intervals of time or when the patient initiates a breath. If you notice in the settings, the ventilator is set to deliver 380 ml of air every 3.3 seconds (rate of 18 per minute). The third breath started earlier than 3.3 second and there was a negative deflection in the pressure first indicating that it is pressure triggered and not time triggered. Once the machine is triggered, it did deliver the tidal volume of 380 mL and ended the inspiration (cycle) after the volume was delivered.

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VBG --> ABG

Seif Hayek
Nader Guma
Mazen Kherallah

Thank you @Abbas Farooqui

Modificato
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65 years old with PMH of hypertension, diabetes, and congestive heart failure. He was admitted with increasing shortness of breath and had to be intubated for hypoxemic respiratory failure secondary to pulmonary edema. Ventilator screenshot is shown above. Notice the two inspirations without expiration in between in almost every breath on the ventilator.


How can you explain these findings on the ventilator?

  • 0%Double triggering

  • 0%Ventilator malfunction

  • 0%Reverse triggering

  • 0%Air leak


Please discuss or place any question in relation to this case in the comment section.

Great answers, indeed this is double triggering. Before I explain this fully, let me ask few questions  @Everyone

  1. what is the total inspired volume in the double triggered breath indicated with the yellow circle?

  2. why the pressure in the first inspiration of the triggered breath is decreased as indicated in the light blue arrow?

  3. Why the pressure in the second triggered inspiration is higher than the first triggered Inspiration indicated with the red arrow?

  4. What do you think the total exhaled air was in the exhalation indicated in the pink circle?

  5. How do you differentiate this from reverse triggering?



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